Text of Final Waiver Approval for Florida Managed Medical Assistance Program

Florida Managed Medical Assistance Program

Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013

CENTERS FOR MEDICARE & MEDICAID SERVICES
SPECIAL TERMS AND CONDITIONS
NUMBER:    11-W-00206/4
TITLE:    Managed Medical Assistance Program
AWARDEE:   Agency for Health Care Administration
I.  PREFACE
The following are the Special Terms and Conditions (STCs) for the Florida Managed Medical
Assistance Program section 1115(a) demonstration (hereinafter “demonstration”).  The parties to
this agreement are the Agency for Health Care Administration (Florida) and the Centers for
Medicare & Medicaid Services (CMS).  The STCs set forth in detail the nature, character, and
extent of federal involvement in the demonstration and the state’s obligations to CMS during the
life of the demonstration.  All previously approved STCs, waivers, and expenditure authorities
are superseded by the STCs set forth below.  The effective date of the demonstration is
December 16, 2011, and is approved through June 30, 2014.

The STCs have been arranged into the following subject areas:
I.  Preface;
II.  Program Description and Objectives;
III.  General Program Requirements;
IV.  Eligibility For Medicaid Reform and the Managed Medical Assistance Program;
V.  Enrollment;
VI.  Benefit Packages and Plans in Medicaid Reform and Managed Medical Assistance
Program;
VII.  Cost Sharing;
VIII.  Florida Managed Medical Assistance Program Implementation;
IX.  Delivery Systems;
X.  Consumer Protections;
XI.    Choice Counseling;
XII.  Enhanced Benefits Account Program;
XIII.  Additional Programs;
XIV.  Low Income Pool;
XV.  Low Income Pool Milestones;
XVI.  General Reporting Requirements;
XVII.  General Financial Requirements;
XVIII.  Monitoring Budget Neutrality;
XIX.  Evaluation of the Demonstration;
XX.  Measurement of Quality of Care and Access to Care Improvement; and,
XXI.  Schedule of State Deliverables.
Attachment A. Quarterly Report Template
Florida Managed Medical Assistance Program     
Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013

II.  PROGRAM DESCRIPTION AND OBJECTIVES
The Florida Medicaid Reform demonstration was approved October 19, 2005.  The state
implemented the demonstration July 1, 2006, in Broward and Duval Counties, and then
expanded to Baker, Clay, and Nassau Counties July 1, 2007.  On December 15, 2011, CMS
agreed to extend the demonstration through June 30, 2014.
The December 2011 renewal included several important improvements to the demonstration,
such as; enhanced managed care requirements to ensure increased stability among managed care
plans, minimize plan turnover, and provide for an improved transition and continuity of care
when enrollees change plans and to ensure adequate choice of providers.  The renewal also
included a Medical Loss Ratio (MLR) requirement of 85 percent for Medicaid operations.
Finally, the renewal included the continuation of the Low Income Pool (LIP) of $1 billion (total
computable) annually to assist safety net providers in providing health care services to Medicaid,
underinsured and uninsured populations.
On June 14, 2013, CMS approved an amendment to the demonstration which retains all of the
improvements noted above, but allows the state to extend an improved model of managed care to
all counties in Florida subject to approval of an implementation plan and a determination of
readiness based on the elements of the approved plan.  The amendment also changes the name of
the demonstration to the Florida Managed Medical Assistance (MMA) program.  Beginning no
earlier than January 1, 2014, the MMA program implementation will begin.  The Medicaid
Reform demonstration will remain in effect in the five Medicaid Reform counties until the MMA
program is implemented.

Under the amended demonstration, most Medicaid eligibles are required to enroll in a managed
care plan (either a capitated managed care plan or a fee-for-service (FFS) Provider Service
Network (PSN) as a condition for receiving Medicaid.  Participation is mandatory for TANF
related populations and the aged and disabled with some exceptions.  The demonstration
continues to allow plans to offer customized benefit packages and reduced cost-sharing, although
each plan must cover all mandatory services, and all state plan services for children and pregnant
women (including EPSDT).  The demonstration provides incentives for healthy behaviors by
offering Enhanced Benefits Accounts that will be replaced by the plan’s Healthy Behaviors
program upon implementation of the MMA program as described in paragraph 65.  Beneficiaries
in counties transitioning from Medicaid Reform to MMA will continue to have access to their
accrued credits under EBAP for one year.

The amended terms and conditions include improvements such as:

  A phased implementation to ensure readiness including a readiness assessment for each
region and a requirement for CMS approval of the state’s implementation plan which will
include identified risks, mitigation strategies, and fail safes, stakeholder engagement and
rapid cycle improvement strategies;
  Strengthened auto-enrollment criteria to ensure consideration of network capacity,
access, continuity of care, and preservation of existing patient-provider relationships
when enrolling all beneficiaries into the MMA program, including special populations;
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
  STCs tailored to special populations, should the state choose to include specialty plans in
the final selection of managed care entities and PSNs;
  Strong consumer protections to ensure beneficiary assistance and continuity of care
through the MMA transition.  Additional STCs to ensure beneficiary choice, including a
comprehensive outreach plan to educate and communicate with beneficiaries, providers,
and stakeholders and annual Health Plan Report Cards for consumers, which will allow
beneficiaries to be more informed on health plan performance and assist beneficiaries in
making informed decisions related to plan selection;
  Enhanced Medical Care Advisory Committee (MCAC) requirements to ensure
beneficiary and advocate group participation as well as inclusion of sub-population
advisory committees;
  Performance Improvement Projects (PIPs) to be performed by all health plans;
  Clarification and enhancements of the monitoring and evaluation of plans to ensure a
rigorous and independent evaluation, and development of rapid cycle, transparent
monitoring in order to ensure continuous progress towards quality improvement; and,
  A Comprehensive Quality Strategy (CQS) that will span the entire Florida Medicaid
program.
Under the demonstration, Florida seeks to continue building on the following objectives:
  Introduce more individual choice, increase access, and improve quality and efficiency
while stabilizing cost;
  Increase the number of individuals in a capitated or premium-based managed care
program and reduce the number of individuals in a fee-for-service program;
  Improve health outcomes and reduce inappropriate utilization;
  Demonstrate that by moving most recipients into a coordinated care-managed
environment, the overall health of Florida’s most vulnerable citizens will improve;
  Serve as an effective deterrent against fraud and abuse by moving from a fee-for-service
to a managed care delivery system;
  Maintain strict oversight of managed care plans including adapting fraud efforts to
surveillance of fraud and abuse within the managed care system;
  Provide managed care plans with flexibility in creating benefit packages to meet the
needs of specific groups; and,
  Provide plans the ability to substitute services and cover services that would otherwise
not be covered by traditional Medicaid.
III.  GENERAL PROGRAM REQUIREMENTS  
1.  Compliance with Federal Non-Discrimination Statutes. The state must comply with
all applicable federal statutes relating to non-discrimination.  These include, but are not
limited to, the Americans with Disabilities Act of 1990, Title VI of the Civil Rights Act
of 1964, section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act
of 1975.
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Approval period: December 16, 2011, through June 30, 2014
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2.  Compliance with Medicaid Law, Regulation, and Policy.  All requirements of the
Medicaid Program expressed in law, regulation, and policy statement not expressly
waived or identified as not applicable in the waiver and expenditure authority documents,
of which these terms and conditions are part, must apply to the demonstration, including
the protections for Indians pursuant to section 5006 of the American Recovery and
Reinvestment Act of 2009.
3.  Changes in Medicaid Law, Regulation, and Policy.  The state must, within the
timeframes specified in law, regulation, or policy statement, come into compliance with
any changes in federal law, regulation, or policy affecting the Medicaid program that
occur during this demonstration approval period, unless the provision being changed is
expressly waived or identified as not applicable.
4.  Impact on Demonstration of Changes in Federal Law, Regulation and Policy.
a)  To the extent that a change in federal law, regulation, or policy requires either a
reduction or an increase in federal financial participation (FFP) for expenditures made
under this demonstration, the state must adopt, subject to CMS approval, a modified
budget neutrality agreement for the demonstration as necessary to comply with such
change.  The modified agreement will be effective upon implementation of the
change.  The trend rates for the budget neutrality agreement are not subject to change
under this subparagraph.
b)  If mandated changes in the federal law, regulation, or policy requires state legislation,
the changes must take effect on the day such state legislation becomes effective, or on
the last day such legislation was required to be in effect under the law.
5.  State Plan Amendments.  The state will not be required to submit a Title XIX state plan
amendment for changes to any populations made eligible solely through the
demonstration. If a population eligible through the Medicaid state plan is affected by a
change to the demonstration, a conforming amendment to the state plan is required,
except as otherwise noted in these STCs.
6.  Changes Subject to the Demonstration Amendment Process.  Changes related to
program design, eligibility, enrollment, benefits, enrollee rights, delivery systems, cost
sharing, LIP, federal financial participation (FFP), sources of non-federal share of
funding, budget neutrality, and other comparable program and budget elements must be
submitted to CMS as amendments to the demonstration.  All amendment requests are
subject to approval at the discretion of the Secretary in accordance with section 1115 of
the Act. The state must not implement changes to these elements without prior approval
by CMS.  Amendments to the demonstration are not retroactive and FFP will not be
available for changes to the demonstration that have not been approved through the
amendment process set forth in paragraph 7, below.
7.  Amendment Process.  Requests to amend the demonstration must be submitted to CMS
for approval no later than 120 days prior to the planned date of implementation of the
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Approval period: December 16, 2011, through June 30, 2014
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change and may not be implemented until approved.  CMS reserves the right to deny or
delay approval of a demonstration amendment based on non-compliance with the STCs,
including but not limited to failure by the state to submit required reports and other
deliverables in a timely fashion according to the deadlines specified herein. Amendment
requests must be accompanied by information that includes but is not limited to the
following:
a)  An explanation of the public process used by the state, consistent with the
requirements of paragraph 16, to reach a decision regarding the requested
amendment;
b)  A data analysis which identifies the specific “with waiver” impact of the proposed
amendment on the current budget neutrality agreement.  Such analysis shall include
current total computable “with waiver” and “without waiver” status on both a
summary and detailed level through the current approval period using the most recent
actual expenditures, as well as summary and detailed projections of the change in the
”with waiver” expenditure total as a result of the proposed amendment, which isolates
by eligibility group the impact of the amendment;
c)  A detailed description of the amendment, including impact on beneficiaries, with
sufficient supporting documentation; and,
d)  If applicable, a description of how the evaluation design will be modified to
incorporate the amendment provisions.
8.  Enhanced Benefits Account Program Phase Out.  The state shall submit a phase-out
plan to CMS for approval no later than 6 months prior to any such time the state proposes
to terminate the Enhanced Benefits Account Program (EBAP) provision of this
demonstration. The EBAP will be limited as follows:
a)  Enrollees will not be able to earn credits for enhanced benefits for deposit into their
account during the last 3 months of the demonstration or the termination of the EBAP
Provision under the demonstration; and
b)  Individuals, who previously earned credits for enhanced benefits in their account, will
continue to have access to funds for health care related expenditures in accordance
with EBAP rules (see paragraph 61).
9.  Extension of the Demonstration.
a)   States that intend to request demonstration extensions under sections 1115(e) or
1115(f) are advised to observe the timelines contained in those statutes.  Otherwise,
no later than 12 months prior to the expiration date of the demonstration, the chief
executive officer of the state must submit to CMS either a demonstration extension
request or a phase-out plan consistent with the requirements of paragraph 10.
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Approval period: December 16, 2011, through June 30, 2014
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b)   As part of the demonstration extension request, the state must provide documentation
of compliance with the transparency requirements in 42 CFR § 431.412 and the
public notice requirements outlined in paragraph 16, as well as include the following
supporting documentation:
i.   Historical Narrative Summary of the Demonstration Project: The state must
provide a narrative summary of the demonstration project, reiterate the objectives
set forth at the time the demonstration was proposed and provide evidence of how
these objectives have been met as well as future goals of the program.  If changes
are requested, a narrative of the changes being requested along with the objective
of the change and desired outcomes must be included.
ii.   Special Terms and Conditions (STCs): The state must provide documentation of
its compliance with each of the STCs.  Where appropriate, a brief explanation
may be accompanied by an attachment containing more detailed information.
Where the STCs address any of the following areas, they need not be documented
a second time.
iii. Waiver and Expenditure Authorities: The state must provide a list along with a
programmatic description of the waivers and expenditure authorities that are
being requested in the extension.
iv. Quality: The state must provide summaries of External Quality Review
Organization (EQRO) reports, health plan state quality assurance monitoring, and
any other documentation of the quality of care provided or corrective action taken
under the demonstration.
v.   Financial Data: The state must provide financial data (as set forth in the current
STCs) demonstrating the state’s detailed and aggregate, historical and projected
budget neutrality status for the requested period of the extension as well as
cumulatively over the lifetime of the demonstration.  CMS will work with the
state to ensure that federal expenditures under the extension of this project do not
exceed the federal expenditures that would otherwise have been made. In doing
so, CMS will take into account the best estimate of current trend rates at the time
of the extension. In addition, the state must provide up to date responses to the
CMS Financial Management standard questions.  If Title XXI funding is used in
the demonstration, a CHIP allotment neutrality worksheet must be included.
vi. Evaluation Report: The state must provide a narrative summary of the evaluation
design, status (including evaluation activities and findings to date), and plans for
evaluation activities during the extension period.  The narrative is to include, but
not be limited to, describing the hypotheses being tested and any results available.
vii. Documentation of Public Notice 42 CFR § 431.408: The state must provide
documentation of the state’s compliance with public notice process as specified in
42 CFR section 431.408 including the post-award public input process described
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Approval period: December 16, 2011, through June 30, 2014
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in 431.420(c) with a report of the issues raised by the public during the comment
period and how the state considered the comments when developing the
demonstration extension application.
10. Demonstration Phase-Out.  The state may only suspend or terminate this
demonstration in whole, or in part, consistent with the following requirements;
a)   Notification of Suspension or Termination: The state must promptly notify CMS in
writing of the reason(s) for the suspension or termination, together with the effective
date and a phase-out plan.  The state must submit its notification letter and a draft
phase-out plan to CMS no less than 6 months before the effective date of the
demonstration’s suspension or termination.  Prior to submitting the draft phase-out
plan to CMS, the state must publish on its website the draft phase-out plan for a 30-day public comment period.  In addition, the state must conduct tribal consultation in
accordance with its approved tribal consultation state plan amendment.  Once the 30-day public comment period has ended, the state must provide a summary of each
public comment received, the state’s response to the comment and how the state
incorporated the received comment into a revised phase-out plan.
The state must obtain CMS approval of the phase-out plan prior to the
implementation of the phase-out activities. Implementation of phase-out activities
must be no sooner than 14 days after CMS approval of the phase-out plan.
b)   Phase-out Plan Requirements: The state must include, at a minimum, in its phase-out
plan the process by which it will notify affected beneficiaries, the content of said
notices (including information on the beneficiary’s appeal rights), the process by
which the state will conduct administrative reviews of Medicaid eligibility for the
affected beneficiaries, and ensure ongoing coverage for eligible individuals, as well
as any community outreach activities.
c)   Phase-out Procedures: The state must comply with all notice requirements found in
42 CFR § 431.206, 431.210 and 431.213. In addition, the state must assure all appeal
and hearing rights afforded to demonstration participants as outlined in 42 CFR §
431.220 and 431.221.  If a demonstration participant requests a hearing before the
date of action, the state must maintain benefits as required in 42 CFR §431.230.  In
addition, the state must conduct administrative renewals for all affected beneficiaries
in order to determine if they qualify for Medicaid eligibility under a different
eligibility category as discussed in October 1, 2010, State Health Official Letter #10-008.
d)   Federal Financial Participation (FFP): If the project is terminated or any relevant
waivers suspended by the state, FFP shall be limited to normal closeout costs
associated with terminating the demonstration including services and administrative
costs of disenrolling participants.
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Approval period: December 16, 2011, through June 30, 2014
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11.  Expiring Demonstration Authority. For demonstration authority that expires prior to
the demonstration’s expiration date, the state must submit a demonstration expiration
plan to CMS no later than 6 months prior to the applicable demonstration authority’s
expiration date, consistent with the following requirements:
a)  Expiration Requirements: The state must include, at a minimum, in its demonstration
expiration plan the process by which it will notify affected beneficiaries, the content
of said notices (including information on the beneficiary’s appeal rights), the process
by which the state will conduct administrative reviews of Medicaid eligibility for the
affected beneficiaries, and ensure ongoing coverage for eligible individuals, as well
as any community outreach activities.
b)   Expiration Procedures: The state must comply with all notice requirements found in
42 CFR § 431.206, 431.210 and 431.213.  In addition, the state must assure all appeal
and hearing rights afforded to demonstration participants as outlined in 42 CFR §
431.220 and 431.221. If a demonstration participant requests a hearing before the date
of action, the state must maintain benefits as required in 42 CFR §431.230. In
addition, the state must conduct administrative renewals for all affected beneficiaries
in order to determine if they qualify for Medicaid eligibility under a different
eligibility category as discussed in October 1, 2010, State Health Official Letter #10-008.
c)   Federal Public Notice: CMS will conduct a 30-day federal public comment period
consistent with the process outlined in 42 CFR § 431.416 in order to solicit public
input on the state’s demonstration expiration plan.  CMS will consider comments
received during the 30-day period during its review and approval of the state’s
demonstration expiration plan.  The state must obtain CMS approval of the
demonstration expiration plan prior to the implementation of the expiration activities.
Implementation of expiration activities must be no sooner than 14 days after CMS
approval of the plan.
d)   Federal Financial Participation (FFP): FFP shall be limited to normal closeout costs
associated with the expiration of the demonstration including services and
administrative costs of disenrolling participants.
12.  CMS Right to Terminate or Suspend.  CMS may suspend or terminate the
demonstration (in whole or in part) at any time before the date of expiration, whenever it
determines following a hearing, that the state has materially failed to comply with the
terms of the project.  CMS will promptly notify the state in writing of the determination
and the reasons for the suspension or termination, together with the effective date.
13. Finding of Non-Compliance.  The state does not relinquish its rights to challenge the
CMS finding that the state materially failed to comply.
14.  Withdrawal of Waiver or Expenditure Authority.  CMS reserves the right to withdraw
waiver or expenditure authorities at any time it determines that continuing the waiver or
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Approval period: December 16, 2011, through June 30, 2014
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expenditure authorities would no longer be in the public interest or promote the
objectives of Title XIX.  CMS will promptly notify the state in writing of the
determination and the reasons for the withdrawal, together with the effective date, and
afford the state an opportunity to request a hearing to challenge CMS’ determination
prior to the effective date.  If a waiver or expenditure authority is withdrawn, FFP is
limited to normal closeout costs associated with terminating the waiver or expenditure
authority, including services and administrative costs of disenrolling participants.
15.  Adequacy of Infrastructure.  The state must ensure the availability of adequate
resources for implementation and monitoring of the demonstration, including education,
outreach, and enrollment; maintaining eligibility systems; compliance with cost sharing
requirements; and reporting on financial and other demonstration components.
16. Public Notice, Tribal Consultation, and Consultation with Interested Parties.  The
state must continue to comply with the state notice procedures set forth in 59 Fed. Reg.
49249 (September 27, 1994) unless they are otherwise superseded by rules promulgated
by CMS.  The state must also comply with the tribal consultation requirements pursuant
to section 1902(a)(73) of the Act as amended by section 5006(e) of the American
Recovery and Reinvestment Act of 2009, when any program changes to the
demonstration, including (but not limited to) those referenced in paragraph 6, are
proposed by the state.  In states with federally recognized Indian tribes, Indian health
programs, and/or Urban Indian organizations, the state is required to submit evidence to
CMS regarding the solicitation of advice from these entities prior to submission of any
waiver proposal, amendment, and/or renewal of this demonstration.
17.  Managed Care Requirements.  The state must comply with the managed care
regulations published at 42 CFR 438. Capitation rates shall be developed and certified as
actuarially sound in accordance with 42 CFR 438.6.  The certification shall identify
historical utilization of state plan services used in the rate development process.
The state must maintain:
a)  Policies to ensure an increased stability among capitated managed care plans and FFS
PSNs and minimize plan turnover.  This could include a limit on the number of
participating plans in the five Medicaid Reform demonstration counties and, when
implemented, in the MMA program.  Plan selection and oversight criteria should
include: confirmation that solvency requirements are being met; an evaluation of
prior business operations in the state; and financial penalties for not completing a
contract term.  The state must report quarterly on the plans entering and leaving
demonstration counties, including the reasons for plans leaving.  The state must
provide these policies to CMS within 90 days of the award of the MMA program
demonstration amendment.
b)  Requirements contained herein are intended to be consistent with and not additional
to the requirements of 42 CFR 438.  Policies to ensure network adequacy and access
requirements which address travel time and distance, as well as the availability of
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routine, urgent and emergent appointments, and which are appropriate for the
enrolled population.  Policies must include documentation and confirmation of
adequate capacity, access to care outside of the network, access to care for enrollees
with special health care needs, and cultural considerations.  The state must implement
a thorough and consistent oversight review for determining plan compliance with
these requirements and report these findings to CMS on a quarterly basis.  The state
must provide these policies to CMS within 90 days of the award of the MMA
program demonstration amendment.
c)  A requirement that each capitated managed care plan and capitated PSN maintain an
annual Medical Loss Ratio (MLR) of 85 percent for Medicaid operations in the
demonstration counties.  These entities must provide documentation to the state and
CMS at least annually to show ongoing compliance.  The state must develop quarterly
reporting of MLR during demonstration year (DY) 6 specific to demonstration
counties. Beginning in DY 7 (July 1, 2012), plans must meet annual MLR
requirements.  MLR requirements are to be reported by the capitated plans 7 months
after the quarter ends to allow for the claims run-out period. CMS will determine the
corrective action for non-compliance with this requirement.
d)  Policies that provide for an improved transition and continuity of care when enrollees
are required to change plans (e.g. transition of enrollees under case management and
those with complex medication needs, and maintaining existing care relationships).
Policies must also address beneficiary continuity and coordination of care when a
physician leaves a health plan and requests by beneficiaries to seek out of network
care.
e)  Policies to ensure adequate choice of providers when there are fewer than two plans
in any rural county, including contracting on a regional basis where appropriate to
assure access to physicians, facilities, and services.
f)  Policies that result in a network of appropriate dental providers sufficient to provide
adequate access to all covered dental services, in accordance with 42 CFR 428.206.
18.  Post Award Forum. Within six months of the demonstration’s implementation, and
annually thereafter, the state will afford the public with an opportunity to provide
meaningful comment on the progress of the demonstration.  At least 30 days prior to the
date of the planned public forum, the state must publish the date, time and location of the
forum in a prominent location on its website.  The state can use either its Medical Care
Advisory Committee, or another meeting that is open to the public and where an
interested party can learn about the progress of the demonstration to meet the
requirements of this STC.  The state must include a summary of the comments and issues
raised by the public at the forum and include the summary in the quarterly report, as
specified in paragraph 90, associated with the quarter in which the forum was held. The
state must also include the summary in its annual report as required in paragraph 91.
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IV.  ELIGIBILITY FOR MEDICAID REFORM AND THE MANAGED MEDICAL
ASSISTANCE PROGRAM
19.  Consistency with State Plan Eligibility Criteria.  There is no change to Medicaid
eligibility.  Standards for eligibility remain set forth under the state plan. There is no
eligibility expansion or reduction under this demonstration except that individuals who
lose Medicaid eligibility will continue for a period of one-year to have access to benefits
accrued in their name under the EBAP. See section XII.
20.  Participation in Medicaid Reform.  The following eligibility requirements remain in
effect for Reform counties until such time that the MMA program is established in the
Reform counties.  Note: the MMA program must not be implemented earlier than January
1, 2014. Reform Participants are individuals eligible under the approved state plan who
reside in Reform Counties who are described below as “mandatory participants” or as
“voluntary participants”.   Mandatory participants are required to enroll in a capitated
managed care plan or FFS PSN as a condition of receipt of Medicaid benefits.  Voluntary
participants are exempt from mandatory enrollment, but have elected to enroll in a
demonstration capitated managed care plan or FFS PSN to receive Medicaid benefits.
a)  Mandatory Participants - Individuals who reside in Reform Counties and who belong
to the categories of Medicaid eligibles listed in the following table and who are not
listed as excluded from mandatory participation are required to be Reform
Participants.
Mandatory State Plan
Groups
Federal Poverty Level (FPL)
and/or Other Qualifying Criteria
Demonstration
Population
(See STC 94)
Infants under age 1  Up to 150 % of the Federal Poverty Level
(FPL)
Population 7
Children 1-5  Up to 133% of the FPL  Population 7
Children 6-18  Up to 100% of the FPL  Population 7
Blind/Disabled Children   Children eligible under SSI  Population 1
TANF Pregnant women  Up to AFDC Income Level (Families whose
income is below the TANF limit – 20% of
the FPL or $303 per month for a family of
3, with assets less than $2,000.)
Population 7
Section 1931 adults   Up to AFDC Income Level (Families whose
income is below the TANF limit – 20% of
the FPL or $303 per month for a family of
3, with assets less than $2,000.
Population 7
Aged/Disabled Adults   Persons receiving SSI whose eligibility is
determined by SSA  
Population 1
Optional State Plan
Groups
Infants under age 1 (Title
XIX funded)
151% up to 185% of the FPL  Population 7
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b)  Voluntary Participants – The following individuals are excluded from mandatory
participation under subparagraph (a) but may choose to be voluntary participants in
the Reform demonstration:
i.  Foster care children;
ii.  Individuals with developmental disabilities not residing in an Intermediate Care
Facility for Individuals with Intellectual Disabilities (ICF-IID);
iii.  Individuals receiving hospice services;
iv.  Pregnant women with incomes above the 1931 poverty level;
v.  Medicare-Medicaid eligible individuals;
vi.  Children under age 1 with family income 186% - 200% of the FPL under Title
XXI; and,
vii.  Children under age 18 eligible for adoption assistance.
c)  Excluded from Reform Participation - The following groups of Medicaid eligibles are
excluded from participation in the demonstration.
i.  Individuals whose immigration status is as a refugee eligible;
ii.  Individuals eligible as medically needy;
iii.  Individuals residing in state mental facilities (age 21 and over);
iv.  Family planning waiver eligibles;
v.  Individuals eligible as women with breast or cervical cancer; and,
vi.  Individuals in an intermediate care facility for individuals with intellectual
disabilities (ICF-IID).
21.  Participation in the MMA program.  The following describes the MMA program
participation. Note: the MMA program must not be implemented earlier than January 1,
2014. MMA program participants are individuals eligible under the approved state plan,
who reside in the MMA program regions and who are described below as “mandatory
participants” or as “voluntary participants”.   Mandatory participants are required to
enroll in a capitated managed care plan or FFS PSN as a condition of receipt of Medicaid
benefits.  Voluntary participants are exempt from mandatory enrollment, but have elected
to enroll in a demonstration capitated managed care plan or FFS PSN to receive Medicaid
benefits.  
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a)  Mandatory Participants - Individuals who reside in one of the eleven regions where
the MMA program has been implemented, who belong to the categories of Medicaid
eligibles listed in the following table, and who are not listed as excluded from
mandatory participation are required to be MMA program participants.
Mandatory State Plan
Groups
Federal Poverty Level (FPL)
and/or Other Qualifying Criteria
Demonstration
Population
(See STC 94)
Infants under age 1  Up to 150% of the Federal Poverty Level
(FPL)
Population 7
Children under age 1   With family income 186% - 200% of the
FPL under Title XXI
Population 7
Children 1-5  Up to 133% of the FPL  Population 7
Children 6-18  Up to 100% of the FPL  Population 7
Blind/Disabled Children   Children eligible under SSI  Population 1
Foster Care  Up to AFDC Income Level (Families whose
income is below the TANF limit – 20% of
the FPL  - Title IV-E)
Population 7
TANF Pregnant women  Up to AFDC Income Level (Families whose
income is below the TANF limit – 20% of
the FPL or $303 per month for a family of
3, with assets less than $2,000.
Population 7
Pregnant women with
incomes above the 1931
poverty level
Income greater than 1931 income level and
not exceeding 150% of FPL.
Population 7
Section 1931 adults   Up to AFDC Income Level (Families whose
income is below the TANF limit – 20% of
the FPL or $303 per month for a family of
3, with assets less than $2,000.)
Population 7
Aged/Disabled Adults   Persons receiving SSI whose eligibility is
determined by SSA  
Population 1
Optional State Plan
Groups
Infants under age 1 (Title
XIX funded)
151% up to 200% of the FPL  Population 7
Adoption assistance under
age 18
Who receive an adoption subsidy  Population 7
Pregnant women with
incomes above the 1931
poverty level
Income greater than 150% of Federal
Poverty Level (FPL) and not exceeding
185% of FPL.
Population 7
Individuals eligible under a
hospice-related eligibility
group
Up to 300% of SSI limit. Income of up to
$2,130 for an individual and $4,260 for an
eligible couple.
Population 1
b) Medicare-Medicaid Eligible Participants- Individuals fully eligible for both Medicare
and Medicaid will be required to participate in the MMA program for covered
Medicaid services.  These individuals will continue to have their choice of Medicare
providers as this program will not impact individuals’ Medicare benefits.  Medicare-Medicaid beneficiaries will be afforded the opportunity to choose an MMA plan.
However, to facilitate enrollment, if the individual does not elect an MMA plan, then
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the individual will be assigned to an MMA plan by the state using the criteria outlined
in STC 23.
c)  Voluntary Participants – The following individuals are excluded from mandatory
participation under subparagraph (a) but may choose to be voluntary participants in
MMAP:
i.  Individuals who have other creditable health care coverage, excluding Medicare;
ii.  Individuals age 65 and over residing in a mental health treatment facility meeting
the Medicare conditions of participation for a hospital or nursing facility;
iii.  Individuals in an intermediate care facility for individuals with intellectual
disabilities (ICF-IID); and
iv.  Individuals with developmental disabilities enrolled in the home and community
based waiver pursuant to state law, and Medicaid recipients waiting for waiver
services.
d)  Excluded From MMA Program Participation - The following groups of Medicaid
eligibles are excluded from participation in the demonstration.
i.  Individuals eligible for emergency services only due to immigration status;
ii.  Family planning waiver eligibles;
iii.  Individuals eligible as women with breast or cervical cancer; and,
iv.  Children receiving services in a prescribed pediatric extended care facility.
Services for individuals who are residing in residential commitment facilities operated
through the Department of Juvenile Justice, as defined in state law, are not eligible for
FFP.
V.  ENROLLMENT
This section describes enrollment provisions that are applicable to Medicaid eligible
individuals living in Florida counties in which either Medicaid Reform or the MMA program
demonstration has been implemented.
22.  New Enrollees. At the time of eligibility determination, individuals who are mandated to
participate must receive information about managed care plan choices in their area.  They
must be informed of their options in selecting an authorized managed care plan.
Individuals must be provided the opportunity to meet or speak with a choice counselor to
obtain additional information in making a choice.  New enrollees will be required to
select a plan within 30 days of eligibility determination.  If the individual does not select
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a plan within the 30-day period, the state may auto-assign the individual into a capitated
managed care plan or a FFS PSN in the Reform Counties or the MMA program when
implemented.  Once individuals have made their choice, they will be able to contact the
state or the state’s designated choice counselor to register their plan selection.  Once the
plan selection is registered and takes effect, the plan must communicate to the enrollee, in
accordance with 42 CFR 438.10, the benefits covered under the plan, including dental
benefits, and how to access those benefits.
23. Auto-Enrollment Criteria.  Each enrollee must be given 30 days to select a managed
care plan after being determined eligible for Medicaid.  Within the 30-day period, the
choice counselor must provide information to the individuals to encourage an active
selection.  Enrollees who fail to choose within this timeframe will be auto-assigned to a
managed care plan.  At a minimum, the state must use the criteria listed below when
assigning an enrollee to a managed care plan.  When more than one managed care plan
meets the assignment criteria, the state will make enrollee assignments consecutively by
family unit.  The criteria include but are not limited to:
a)  A managed care plan has sufficient provider network capacity, including dental
network capacity, to meet the needs of enrollees;
b)  The managed care plan has previously enrolled the enrollee as a member, or one of
the plan’s primary care providers has previously provided health care to the enrollee;
c)  The state has knowledge that the enrollee has previously expressed a preference for a
particular managed care plan as indicated by Medicaid FFS claims data, but has failed
to make a choice; and,
d)  The managed care plan's primary care providers are geographically accessible to the
recipient's residence.
24.  Auto Enrollment for Special Populations.  For an enrollee who is also a recipient of
Supplemental Security Income (SSI), prior to assigning the SSI beneficiary to a managed
care plan, the state must determine whether the SSI beneficiary has an ongoing
relationship with a provider or managed care plan; and if so, the state must assign the SSI
recipient to that managed care plan whenever feasible.  Those SSI recipients who do not
have such a provider relationship must be assigned to a managed care plan using the
assignment criteria previously outlined.
In addition, the state must use the following parameters when assigning a recipient to a
plan.
a)  To promote alignment between Medicaid and Medicare, each beneficiary who is
enrolled with a Medicare Advantage Organization, must first be assigned to any
MMA plan in the beneficiary’s region that is operated by the same parent
organization as the beneficiary’s Medicare Advantage Organization. If there is no
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match of parent organization or appropriate plan within the organization, then the
beneficiary should be assigned as in paragraphs (a)-(d) above.
b)  If an applicable specialty plan is available, the recipient should be assigned to the
specialty plan.
c)  If, in the first year of the first contract term only, a recipient was previously enrolled
in a plan that is still available in the region, the recipient should be assigned to that
plan.
d)  Newborns of eligible mothers enrolled in a plan at the time of the child’s birth will be
automatically enrolled in that plan; however, the mother may choose another plan for
the newborn within 90 days after the child’s birth.
e)  Foster care children will be assigned/re-assigned to the same plan/PCP to which the
child was most recently assigned in the last 12 months, if applicable.
25. Lock-In/Disenrollment. Once a mandatory enrollee has selected or been assigned a
Medicaid Reform plan or MMA plan, the enrollee shall be enrolled in the plan for a total
of 12 months, which includes a 90-day disenrollment period.  Once an individual is
enrolled into a plan the individual must have 90 days to voluntarily disenroll from that
plan without cause and select another plan.  If an individual chooses to remain in the plan
past 90 days the individual will remain in the selected plan for an additional nine months
for a total enrollment period of 12 months, and no further changes may be made until the
next open enrollment period, except for cause.  Cause shall include: enrollee moves out
of the plan’s service area; enrollee needs related services to be performed at the same
time, but not all related services are available within the network; and the enrollee’s
treating provider determines that receiving the services separately would subject the
enrollee to unnecessary risk.  Other reasons for cause may include but are not limited to:
quality of care, lack of access to necessary services, an unreasonable delay or denial of
services, inordinate or inappropriate changes of primary care providers, service access
impairments due to significant changes in the geographic location of services, or
fraudulent enrollment.  Enrollees may transfer between primary care providers within the
same managed care plan. Voluntary enrollees may disenroll from the plan at any time.
The choice counselor or state will record the plan change/disenrollment reason for all
recipients who request such a change.  The state or the state’s designee will be
responsible for processing all enrollments and disenrollments.
26. Re-enrollment. In instances of a temporary loss of Medicaid eligibility, which the state
is defining as 6 months or less, the state will re-enroll demonstration enrollees in the
same capitated managed care plan or FFS PSN they were enrolled in prior to the
temporary loss of eligibility unless enrollment into the entity has been suspended.
VI.  BENEFIT PACKAGES and PLANS in MEDICAID REFORM AND MMA
PROGRAM
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27.  Customized Benefit Packages. Capitated managed care plans will have the flexibility to
provide customized benefit packages for demonstration enrollees as long as the benefit
package meets certain minimum standards described in this STC, and actuarial benefit
equivalency requirements and benefit sufficiency requirements described in STCs 28-32.
PSNs operating under FFS must provide all benefits for all enrolled beneficiaries as are
available under the state plan.  The customized benefit packages must include all state
plan services otherwise available under the state plan for pregnant women and children
including all EPSDT services for children under age 21.  The customized benefit
packages must include all mandatory services specified in the state plan for all
populations.  The amount, duration and scope of optional services, may vary to reflect the
needs of the plan’s target population and plans can offer additional services and benefits
not available under the state plan.  The plans contracted with the state shall not have
service limits more restrictive than authorized in the state plan for children under the age
of 21, pregnant women, and emergency services.  The state may also capitate all state
plan services for demonstration enrollees.
Policies for determining medical necessity for children covered under the EPSDT benefit
must be consistent with Federal statute at §1905(r) of the Social Security Act (the Act) in
authorizing vision, dental, and hearing services, and other necessary health care,
diagnostic services, treatment and other measures described in §1905(a) of the Act to
correct or ameliorate defects and physical and mental illnesses and conditions discovered
by screening services, whether or not such services are covered in the State plan.
28.  Overall Standards for Customized Benefit Packages.  All benefit packages must be
prior-approved by the state and must be at least actuarially equivalent to the services
provided to the target population under the current state plan benefit package.  In addition
the plan’s customized benefit package must meet a sufficiency test to ensure that it is
sufficient to meet the medical needs of the target population.
29.  Plan Evaluation Tool.  The state will utilize a Plan Evaluation Tool (PET) to determine
if a plan that is applying for a Medicaid Reform Plan contract or has been awarded an
MMA plan contract meets state requirements. The PET measures for actuarial
equivalency and sufficiency.  Specifically, it 1) compares the value of the level of
benefits (actuarial equivalency) in the proposed package to the value of the current state
plan package for the average member of the population and 2) ensures that the overall
level (sufficiency) of certain benefits is adequate to cover the vast majority of enrollees.
The state will evaluate service utilization on an annual basis and use this information to
update the PET to ensure that actuarial equivalence calculations and sufficiency
thresholds reflect current utilization levels.
30.  Plan Evaluation Tool: Actuarial Equivalency.  Actuarial equivalence is evaluated at
the target population level and is measured based on that population’s historical
utilization of services for current Medicaid state plan services.  This process ensures that
the expected claim cost levels of all managed care plans are equal (using a common
benchmark reimbursement structure) to the level of the historic FFS plan for the target
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Amended June 14, 2013   
population and its historic levels of utilization.  The state uses this as the first threshold to
evaluate the customized benefit package submitted by a plan to ensure that the package
earns the premium established by the state.  In assessing actuarial equivalency, the PET
considers the following components of the benefit package: services covered; cost
sharing; and additional benefits offered, if any.  Additional services offered by the plan
will be considered a component of the plan’s customized benefits and not a component of
the Enhanced Benefit Plan.
31.  Plan Evaluation Tool: Sufficiency.  In addition to meeting the actuarial equivalence
test, each health plan’s proposed customized benefit package must meet or exceed, and
maintain, a minimum threshold of 98.5 percent for benefits identified as sufficiency
tested benefits.  The sufficiency test provides a safeguard when plans elect to vary the
amount, duration and scope of certain services.  This standard is based on the target
population’s historic use of the applicable Medicaid state plan services (e.g. outpatient
hospital services, outpatient pharmacy prescriptions) identified by the state as sufficiency
tested benefits.  Each proposed benefit plan must be evaluated against the sufficiency
standard to ensure that the proposed benefits are adequate to cover the vast majority of
enrollees.  The sufficiency standard for a service may be based on the proportion of the
historical utilization for the target population that is expected to exceed the plan’s
proposed benefit level.
32.  Evaluation of Plan Benefits.  The state will review and update the PET for assessing a
plan’s benefit structure to ensure actuarial equivalence and that services are sufficient to
meet the needs of enrollees in the demonstration area.  At a minimum, the state must
conduct the review and update on an annual basis.  The state will provide CMS with 60-days advance notice and a copy of any proposed changes to the PET.
VII.  COST SHARING
33. Premiums and Co-Payments.  The state must pre-approve all cost sharing allowed by
Reform and MMA plans.  Cost-sharing must be consistent with the state plan except that
managed care plans may elect to assess cost sharing that is less than what is allowed
under the state plan.
VIII.  FLORIDA MANAGED MEDICAID ASSISTANCE (MMA) PROGRAM
IMPLEMENTATION
34.  Reform Implementation. Counties where Reform was implemented in 2006 and 2007
are known as Reform Counties (Baker, Broward, Clay, Duval, and Nassau).  No earlier
than January 1, 2014, these counties will become MMA program counties when the
MMA program is implemented in their respective region.  Transition from Medicaid
Reform counties to the MMA regions will follow implementation requirements as
outlined in STCs 35 and 36.
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35. MMA Program Implementation Requirements.  No earlier than January 1, 2014, the
state may implement the MMA program in a region if it meets the following
implementation requirements for that region (subject to CMS review and approval).
Implementation Schedule: The state must submit to CMS a schedule indicating its
planned start date for mandatory enrollment in the MMA program in each region of the
state.  The state may not begin mandatory enrollment in any region until CMS has
approved the implementation plan.  After CMS’ approval of the implementation plan, the
state may stagger mandatory enrollment over period beginning no earlier than January 1,
2014.  The state will submit an implementation schedule to CMS by October 31, 2013,
that specifies the regions to be transitioned in that timeframe with a staggered
implementation approach.  The state may revise the implementation schedule as needed,
and must promptly notify CMS of any changes.  The approved implementation plan will
become a future attachment to these STCs.
a)  The plan must include:
i.  Identification of triggers that would prevent the state from proceeding with the
next regional area for implementation;
ii.  Identification of risks with the implementation;
iii.  A mitigation strategy for the identified risks;
iv.  A fail-safe or back-up plan in the event that the mitigation strategy fails;
v.  Identification of circumstances that would stop the state proceeding with the
implementation of the next region;
vi.  The role of stakeholder feedback in determining further implementation of the
next region; and
vii.  A detailed description of the rapid cycle improvement process and electronic
tracking system.
The state is required to submit an amendment no later than October 31, 2013 to Florida’s
Section 1915(b) Medicaid Managed Care Waiver, control # FL-01.R08, to reflect the
phase out of that waiver.
b)  Transition plan. The state must conduct an assessment of the plan transition needs
for each region and will explain its policies to promote beneficiary continuity and
continuation of care, particularly for beneficiaries who will no longer have access to
his or her physician and beneficiaries who are enrolled in a managed care plan for
their managed long term services and supports.
c)  Notice information. The state must provide notice of the change in program
authority and open enrollment to individuals in each region in simple and
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Amended June 14, 2013   
understandable terms and in a manner that is accessible to persons who are limited
English proficient and individuals living with disabilities.
d)  Readiness review. The state must assess plan readiness in each region in accordance
with the requirements of 42 CFR 438.  Readiness reviews will include, but are not
limited to, documentation and confirmation of adequate capacity, access to care
outside of the network, access to care for enrollees with special health care needs, and
cultural considerations.  The state will also notify CMS of its intent to conduct a
readiness review 30 days in advance of the review and provide CMS the opportunity
to observe the readiness review.  The state will provide CMS a copy of their readiness
review feedback/corrective action plan letter and approval letters for each readiness
review.
e)  Solvency assessment.  In accordance with STC 17, Managed Care Requirements, the
state must evaluate the prior business operations of all health plans that apply to
operate in the region, and confirm that they meet solvency standards.  The state’s
managed care contract must include penalties for plans that do not complete the
contract term.
f)  Compliance with Managed Care requirements. The state must assure that all
managed care plans in the region comply with all of the managed care requirements
described in paragraph 17 of these special terms and conditions and EPSDT
requirements described in paragraph 27 of these STCs.
g)  Prior to implementation in each region, the state must submit a report to CMS on its
compliance with subparagraphs (b) through (f) above, along with the most recent
version of the implementation schedule mentioned in (a).  The state may not initiate
mandatory MMA program enrollment in a region unless CMS has received this report
at least 30 days in advance of the implementation date for each region(s).
36. MMA Program Regions. The MMA program shall be implemented over a period
beginning no earlier than January 1, 2014 and no later than October 1, 2014, as described
in paragraph 35.  The MMA program implementation regions are defined as follows:
Region  Counties
Region 1:   Escambia, Okaloosa, Santa Rosa and Walton
Region 2:   Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson,
Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, and
Washington
Region 3:   Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist,
Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam,
Sumter, Suwannee, and Union
Region 4:   Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
Region 5:   Pasco and Pinellas  
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Amended June 14, 2013   
Region 6:   Hardee, Highlands, Hillsborough, Manatee and Polk
Region 7:   Brevard, Orange, Osceola and Seminole
Region 8:   Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
Region 9:   Indian River, Martin, Okeechobee, Palm Beach and St. Lucie
Region 10:   Broward
Region 11:   Miami-Dade and Monroe
IX.  DELIVERY SYSTEMS
37.  Health Plans.  Health plans authorized under this demonstration must be authorized by
state statute and must adhere to 42 CFR 438.  Contracts with these entities may be risk or
non-risk contract types.  Capitation rates shall be developed and certified as actuarially
sound in accordance with 42 CFR 438.6.  The certification shall identify historical
utilization of state plan services used in the rate development process.  The final contracts
developed to implement selective contracting by the state with any managed care
organization, provider group, Prepaid Inpatient Health Plan (PIHP) or Prepaid
Ambulatory Health Plan (PAHP) shall be subject to CMS Regional Office approval prior
to implementation.
a)  Capitated Managed Care Organization – An entity (such as Health Maintenance
Organization, Accountable Care Organization, capitated Provider Service Network,
or Exclusive Provider Organization) that meets the definition of managed care
organization (MCO) as described in 42 CFR 438.2, and which must conform to all of
the requirements in 42 CFR 438 that apply to MCOs.
b)  Provider Service Network (PSN) – An entity established or organized by a health care
provider or group of affiliated health care providers that meet the requirements of
Florida Statutes.   A PSN may be reimbursed on a FFS or capitated basis as specified
in state statute.  Capitated PSNs are categorized as MCOs, and must meet the
requirements as described in 42 CFR 438.
c)  Prepaid Inpatient Health Plan (PIHP), Prepaid Ambulatory Health Plan (PAHP)-Entities that meet the definition or PIHP or PAHP as described in 42 CFR 438.2 and
which must conform to all requirements in 42.CFR 438 that apply to PIHPs and
PAHPs.
38.  Number of Plans per Region.  The state will procure a specified number of plans per
region for the MMA program.  A minimum and maximum number of plans are specified
by region, with a minimum of two plans choices in each of the 11 regions.  Of the total
contracts awarded per region, at least one award shall be a PSN if any PSNs submit a
responsive bid.  Issuance and award of the procurements will provide for a choice of
plans, as well as market stability.
Should the state not be able contract with at least two plans in a region that is not rural,
the state will issue another procurement to obtain a second plan and meet the federal
requirements in 438.52.  Until two plans are available in the impacted region,
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Amended June 14, 2013   
beneficiaries may voluntarily choose to enroll in the available managed care plan or to
access services through a FFS delivery system.
In addition to regional plans, the state will also seek to contract with specialty plans, as
discussed in STC 40.  Participation of specialty plans will be subject to competitive
procurement requirements but will not be considered in assessing regional plan
availability.  However, the state may not enter into contracts with specialty plans to the
extent that the target populations include more than 10 percent of the enrollees of any one
region.
Once the state has selected the managed care plans for the MMA program through its
competitive bidding process, the state will submit a report to CMS no later than October
31, 2013, that will include:
a)  The name of the managed care plans selected for each region;
b)  For the selected plans, please identify those plans that also provide long term services
and supports under the 1915(b)(c) waivers;
c)  The names of managed care plans that will not be continuing by region; and,
d)  The number of enrolled beneficiaries in each plan that will not be continuing.
39.  Freedom of Choice.  An enrollee’s freedom of choice of providers shall be limited to
and through whom individuals may seek services, including the EBAP for populations
enrolled in the Florida Medicaid Reform demonstration.  The state must provide
demonstration enrollees access to the FFS delivery systems as necessary to meet the
choice requirements as under 42 CFR 438.52.
a)  Beneficiaries also have a choice of at least two regional health plans in each region.
While beneficiaries are encouraged to select the same MMA plan as their Medicare
Advantage or LTC Plan, it is not a requirement.
b)  Should a beneficiary choose an MMA health plan that is different from their
Medicare Advantage or LTC plan, the two entities must coordinate the beneficiaries
care to ensure that all needs are met.
40.  Specialty Plans.  The contracted plans in the MMA program regions will be encouraged
to develop and offer specialty plans to serve individuals with specific conditions or select
eligibility groups.
A specialty plan is defined as a plan that exclusively enrolls, or enrolls a disproportionate
percentage of, special needs individuals and that has been approved by the state as a
specialty plan.  Specialty plans are designed for a specific population and currently
include plans that primarily serve children with chronic conditions or recipients who have
been diagnosed with the human immunodeficiency virus or acquired immunodeficiency
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syndrome (HIV/AIDS).  Participation of specialty plans will be subject to competitive
procurement requirements and the aggregate enrollment of all specialty plans in a region
may not exceed 10 percent of the enrollees of that region.
The state will identify specialty plans as part of the procurement process and may
approve specialty plans on a case-by-case basis using criteria that include appropriateness
of the target population and the existence of clinical programs or special expertise and/or
providers to serve that target population. The state will not approve plans that
discriminate against sicker members of a target population.
The state may also contract with Medicare Advantage Organizations, to serve Medicare-Medicaid enrollees, authorized by the Centers for Medicare & Medicaid Services.
In addition to meeting general financial reserve requirements and network sufficiency
requirements, the state will develop enhanced standards for specialty plans that may
include but are not limited to:
a)  Appropriate integrated provider network of primary care physicians and specialists
who are trained to provide services for a particular condition or population.  The
network should be an integrated network of primary care physicians (e.g.,
nephrologists for kidney disease; cardiologists for cardiac disease; infectious disease
specialists and immunologists for HIV/AIDS).
b)  Network with sufficient capacity of board-certified specialists in the care and
management of the disease for plans that seek to focus services for enrollees with a
particular disease state.  In addition, it is recognized that individuals have multiple
diagnoses, and, therefore, the plan should have sufficient capacity of additional
specialists to manage the different diagnoses.
c)  Defined network of facilities that are used for inpatient care, including the use of
accredited tertiary hospitals and hospitals that have been designated for specific
conditions (e.g., end stage renal disease centers, comprehensive hemophilia centers).
d)  Availability of specialty pharmacies, where appropriate.
e)  Availability of a range of community-based care options as alternatives to
hospitalization and institutionalization.
f)  Clearly defined coordination of care component that links and shares information
between and among the primary care provider, the specialists, and the patient to
appropriately manage co-morbidities.
g)  Use of evidence-based clinical guidelines in the management of the disorder.
h)  Development of a care plan and involvement of the patient in the development and
management of the care plan, as appropriate.
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Amended June 14, 2013
i)  Development and implementation of a disease management program specific to the
specialty population(s) or disease state(s), including a specialized process for
transition of enrollees from disease management services outside of the plan to the
plan’s disease management program.
41.  Incentives are included for plans that exceed Agency defined quality measures. Plans
that exceed such measures during a reporting period may retain an additional 1 percent of
revenue.
42.  Requirements for Special Populations.
a)  HIV Specialty Plans
i.  The state will mandatorily enroll Medicaid beneficiaries identified with a
diagnosis of HIV or AIDS to a specialty plan, where available, and when the
beneficiary does not select an MMA plan during the 30 day choice period.  These
beneficiaries may be identified with a combination of diagnosis codes on current
claims; HIV or AIDS prescription medications; and laboratory tests and results.
ii.  The state will notify beneficiaries identified with a diagnosis of HIV or AIDS in
writing that the beneficiary must select an MMA plan during the 30 day choice
period or the beneficiary will be assigned to a specialty plan available in his or her
region.  The notification will provide the beneficiary with information regarding
the benefits of enrolling in a specialty plan and the 90 day period to make another
plan selection without cause.
iii.  When making assignments to an HIV/AIDS specialty plan, the state will consider
the beneficiary’s PCP and/or current prescriber of HIV or AIDS medications.
iv.  When making assignments to HIV/AIDS specialty plans and the beneficiary’s
PCP or current prescriber of HIV or AIDS medications is not known or is not an
enrolled provider with a specialty plan, the state will assign the beneficiary to a
specialty plan available on a rotating basis.
v.  When making assignments to HIV/AIDS specialty plans of beneficiaries who are
determined to have co-morbid conditions, the state may assign the beneficiary to
the most appropriate specialty plan available in the beneficiary’s region.
b)  Children’s Specialty Plans
i.  The State may elect to contract with Children’s Specialty Plans to serve Foster
Care Children. These plans will have special requirements for immediate
assessment, care coordination, and treatment of Foster Care Children. The
Children’s Specialty Plans are required to furnish EPSDT for Foster Care
Children and follow the State’s medication formulary for first year of the MMA
Program.   
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ii.  During the plan selection period, the Foster Care child’s legal guardian may
choose to enroll in an MMA health plan or the Children’s Specialty Plans that are
available in the child’s region.
iii.  Should a Foster Care child’s legal guardian fail to make an affirmative selection
of an MMA health plan, the state may enroll the foster care child into the
Children’s Specialty Plan available in the region.
X.  CONSUMER PROTECTIONS
43. Medical Care Advisory Committee.  In accordance with 42 C.F.R. §431.12, the state
must maintain its Medical Care Advisory Committee (MCAC) to advise the Medicaid
agency about health and medical care services. The state must ensure that the MCAC is
comprised of the representatives set forth in 42 C.F.R. §431.12(d). The state must ensure
that the MCAC includes representation of at least four beneficiaries at all times and
report to CMS any vacant beneficiary slots that are not filled within 90 days of the date of
this amendment or within 90 days of becoming vacant.  The state may submit
justification to CMS for an unfilled beneficiary slot after 90 days and CMS may grant an
exception to this requirement at CMS’ discretion.  The MCAC must present
recommendations and suggestions to the state on the state’s comprehensive quality
strategy, as described in STC 118.
Subpopulation Advisory Committees.  In addition to the MCAC, the state must
convene smaller advisory committees that meet on a regular basis (at least quarterly) to
focus on subpopulations, including, but not limited to: beneficiaries receiving managed
long-term services and supports; beneficiaries with HIV/AIDS; children, including
safeguards and performance measures related to foster children and the provision of
dental care to all children; and beneficiaries receiving behavioral health/substance use
disorder services.
Each advisory committee must include representation from relevant advocacy
organizations, as well as beneficiaries.  Each advisory committee must present
recommendations and suggestions to the state on the state’s comprehensive strategy, as
set forth in STC 118. In addition, each advisory committee must provide input to the
state on the consumer report cards, set forth in STC 115.
44.  Appointment Assistance.  The state must provide, or ensure the provision of, necessary
assistance with transportation and with scheduling appointments for medical, dental,
vision, hearing, and mental health.
45.  Attempts To Gain an Accurate Beneficiary Address.  The state shall implement the
CMS approved process for return mail tracking.  The state will use information gained
from return mail to make additional outreach attempts through other methods (phone,
email, etc.) or complete other beneficiary address analysis from previous claims to
strengthen efforts to obtain a valid address.   
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46.  Verification of Beneficiary’s Health plan Enrollment. The state shall utilize and
publicize for health plan network and non-network providers the following eligibility
verification processes for beneficiaries’ eligibility to be verified so that beneficiaries will
not be turned away for services if the beneficiary does not have a card or presents the
incorrect card. Providers with a valid Medicaid provider number may use any of the
following options to determine enrollee eligibility:
a)  Utilize the Medicaid Eligibility Verification System (MEVS): eligibility transactions
may be submitted using computer software supplied by the vendor, via a point of sale
device similar to those used for credit card transactions, over the telephone using a
voice response system, or other possibilities depending on what the MEVS vendor
offers;
b)  Perform single transactions (individual verifications) or batch transactions via a
secure area on the Medicaid fiscal agent’s web portal;
c)  Utilize the Automated Voice Response System (AVRS): providers enter information
via a touchtone telephone and it generates a report with all of the eligibility
information for a particular recipient, which can be faxed to the provider’s fax
machine;
d)  Submit eligibility transactions via the Electronic Data Interchange (EDI);
e)  Contact the Medicaid fiscal agent’s Provider Services Contact Center at 1-800-289-7799; or,
f)  Contact their local Medicaid area office for assistance.
47. Call Center Availability. The state must keep the existing (non-continuing) health plan
call centers open for the first month of implementation to direct callers to either the state,
the enrollment broker, or their new health plan.
48.  Sample Notification Letters. The state must send sample beneficiary notification letters
to the existing Medicaid providers, either through direct mailing, posted on the MMA
program website, or other widely distributed method, so providers are informed of what
is being told to the beneficiaries regarding their transition to the MMA program.
49.  Educational Tour and Outreach for Beneficiaries, Providers, and Stakeholders.
a)  The state must develop a comprehensive outreach plan to include strategies for
communicating with beneficiaries throughout the implementation process.  The
outreach plan should identify ways in which the state will work collaboratively with
beneficiaries, and stakeholders, including the enrollment broker, choice counseling
entities, and any other group providing enrollment support for beneficiaries or
providers through written notice distribution, outgoing phone calls or other method.
The state must initiate beneficiary outreach at least 90 days prior to the
implementation of the MMA program in a region and continue through the first 90
days after the implementation of the MMA program.       
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b)  The state must develop a comprehensive outreach plan to include strategies for
communicating with providers throughout the implementation process.  The outreach
plan should identify ways in which the state will work collaboratively with providers
and health plans to address providers’ questions and concerns regarding
implementation.  Communication and technical assistance to providers should include
webinars, trainings on various topics, Q &A documents, and telephone assistance as
applicable.
50. Continuation of Care During the Transition Period.  Beneficiaries whose health plans
will not continue in their region under the MMA program may continue to receive
services from their treating provider for up to 60 calendar days after their enrollment
effective date under their new MMA health plan.  
a)  Communication regarding the continuation of services will be publicized through the
State’s outreach and community strategy to beneficiaries, providers, and the general
public.
b)  Health plans will be required to authorize services and reimburse providers whether
the provider is contracted with the health plans or an out of network provider.
c)  If the health plan has not contracted with the treating provider, the health plan must
notify enrollees before the 90 day disenrollment period has ended, that they will not
be able to continue with the treating provider  and provide the option to either:
i.  Continue services with a network provider; or,
ii.  Disenroll for cause.
51. Operated Call Center Operations. The state must operate a call center(s) independent
of the health plans for the duration of the demonstration. This can be achieved either by
providing the call center directly or through the enrollment broker or other state
contracted entities.  Call center operations should be able to help enrollees in making
independent decisions about plan choice, and be able to voice complaints about each of
the health plans independent of the health plans.
52.  Call Center Response Statistics.  During the first 30 days of implementation the state
must review all call center response statistics daily to ensure all contracted entities are
meeting service level agreements in their contracts. If deficiencies are found, the state
and the entity must determine how they will remedy the deficiency as soon as possible.
After the first 30 days, if all entities are consistently meeting requirements, the state can
lessen the review of call center statistics, but must still review all statistics at least weekly
for the first 60 days of implementation.  Data and information regarding call center
statistics, including beneficiary questions and concerns, must be made available to CMS
upon request.
53. Auto-assignment Algorithm Review.  The state must review the outcomes of the auto-assignment algorithm, and if a health plan is found to get a larger number of beneficiaries
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associated with no match to an existing provider relationship due to a more limited
network, that entity will not be able to receive as many auto-assignees until such time as
the network has improved.
54.  Implementation Calls with the Health Plans.  The state must develop a schedule of
calls with health plans during implementation of MMA program to discuss any issues
that arise.  The state must submit a copy of the schedule of implementation calls to CMS
and allow CMS the opportunity to participate in the state’s implementation calls with
health plans.  The calls should cover all health plans operations and determine plans for
correcting any issues as quickly as possible.  For the first 60 days in which the region
transitions to the MMA program CMS will require weekly reporting of issues
encountered and plans for and status of resolution during the Implementation Monitoring
conference calls specified in STC 89.
55.  State Review of Beneficiary Complaints, Grievances, and Appeals.  During the initial
implementation of MMA program, the state must review complaint, grievance, and
appeal logs for each health plan and data from the state or health plan operated incident
management system, to understand what issues beneficiaries and providers are having
with each of the health plans.  The state will use this information to implement any
immediate corrective actions necessary.  The state must review these statistics at least
weekly for the first 60 days in which the region transitions to the MMA program.  The
state will continue to monitor these statistics throughout the demonstration period and
report on them in the quarterly reports as specified in STC 90.  Data and information
regarding the beneficiary complaints, grievances, and appeals process must be made
available to CMS upon request.
XI.  CHOICE COUNSELING
56.  Choice Counseling Defined.  The state shall contract for choice counselor services in
Reform Counties and the MMA program regions to provide full and complete
information about managed care plans choices.  The state will ensure a choice counseling
system that promotes and improves health literacy and provides information to reduce
minority health disparities through outreach activities.
57. Choice-Counseling Materials.  Through the choice counselor the state offers an
extensive enrollee education and rating system so individuals will fully understand their
choices and be able to make an informed selection.  Outcomes important to enrollees will
be measured consistently for each plan, and the data will be made available publicly.
58. Choice Counseling Information. The state or the state’s administrator provides
information on selecting a managed care plan.  The state or the state’s designated choice
counselor provides information about each plan’s coverage in accordance with federal
requirements.  Information includes but is not limited to, benefits and benefit limitations,
cost-sharing requirements, network information, contact information, performance
measures, results of consumer satisfaction reviews, and data on access to preventive
services.  In addition, the state may supplement coverage information by providing
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performance information on each plan.  The supplement information may include
medical loss ratios that indicate the percentage of the premium dollar attributable to
direct services, enrollee satisfaction surveys and performance data.  To ensure the
information is as helpful as possible, the state may synthesize information into a coherent
rating system.
59.  Delivery of Choice Counseling Materials.  Choice counseling materials will be
provided in a variety of ways including the internet, print, telephone, and face-to-face.
All written materials shall be at the fourth-grade reading level and available in a language
other than English when 5 percent of the county speaks a language other than English.
Choice counseling shall also provide oral interpretation services, regardless of the
language, and other services for impaired recipients, such as TTD/TTY, without charge
to the enrollee.
60. Contacting the Choice Counselor.  Individuals contact the state or the state’s designated
choice counselor to obtain additional information.  Choice counseling and enrollment
information is available at the Agency for Health Care Administration’s website or by
phone.  The state or the choice counselor will operate a toll-free number that individuals
may call to ask questions and obtain assistance on managed care options.  The call center
will be operational during business days, with extended hours, and will be staffed with
professionals qualified to address the needs of the enrollees and potential enrollees.  The
state must ensure mechanisms are in place to monitor and evaluate choice counseling call
center metrics and the individual performance of choice counseling personnel.
XII.  ENHANCED BENEFITS ACCOUNT PROGRAM UNDER MEDICAID REFORM
AND HEALTHY BEHAVIORS PROGRAM UNDER THE MMA PROGRAM
61.  Medicaid Reform Enhanced Benefits Account Program Defined.  The EBAP
provides incentives to capitated managed care plan or FFS PSN enrollees for
participating in state defined activities that promote healthy behaviors.  An individual
who participates in a state defined activity that promotes healthy behaviors earns credits
that are posted to an individual’s account.  Earned credits may be used for health care
related expenditures as approved under the EBAP and defined in Section 1905 of the Act.
EBAP is available only in Medicaid Reform counties prior to implementation of the
managed care plan’s Healthy Behaviors programs under the MMA program.  The only
exception is that recipients who have accrued Enhanced Benefits credits will be able to
access the credits for up to one year.
62.  Medicaid Reform EBAP Administration Overview.  The state will maintain a list of
activities that generate contributions to the account.  A menu of benefits or programs will
be provided as will the individual value of each item on the menu.  The amount available
to individuals from their enhanced benefit account will depend on the activities in which
they participate up to a maximum amount.  Once an enrollee completes an approved
activity, the enrollee will be considered an active participant.  The state will post earned
credits into an account for use by the enrollee.  Additional credits may be earned as the
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enrollee participates in additional activities.  In no instance will the individual receive
cash.
63.  Medicaid Reform Participants Earning Enhanced Benefits Accounts Defined.  All
enrollees in a Reform plan, including mandatory and voluntary enrollees, will be eligible
to participate in activities to earn enhanced benefits for the duration of their enrollment.
The exception to this provision is at the time of EBAP phase out as discussed in Section
III, “General Program Requirements”.
64.  Expansion Population for the Continuation of the EBAP.  In Medicaid in Reform
counties, individuals who lose eligibility or transition to MMAP will continue to have
limited eligibility under this demonstration for a period of one year.  This population
retains eligibility under the demonstration solely to access accrued funds in their
individual enhanced benefits account for a period of one year.  Individuals who lose
eligibility for Medicaid will receive no other benefits than those available through the
EBAP.  This population is limited to individuals who have accrued funds in an individual
enhanced benefit account. Upon implementation of the MMA program, recipients who
have accrued credits under Medicaid Reform will be able to access those credits for up to
one year. These individuals are identified as demonstration Population A.
65.  Healthy Behaviors Programs Under the MMA Program. Through its procurement
process, the state must require the managed care plans operating in the MMA program
counties to establish Healthy Behaviors programs to encourage and reward healthy
behaviors.  For Medicare and Medicaid recipients who are enrolled in both an MMA plan
and a Medicare Advantage plan, the MMA plan must coordinate their Healthy Behaviors
programs with the Medicare Advantage plan to ensure proper coordination.
a)  The state must monitor to ensure that each plan has, at a minimum, a medically
approved smoking cessation program, a medically directed weight loss program, and
a substance abuse treatment plan that meet all state requirements.
b)  Programs administered by plans must comply with all applicable laws, including
fraud and abuse laws that fall within the purview of the United States Department of
Health and Human Services, Office of Inspector General (OIG).  Plans are
encouraged to seek an advisory opinion from OIG once the specifics of their Healthy
Behaviors programs are determined.
66.  Participant Access to Credits Under Medicaid Reform (EBAP) and MMA (Healthy
Behaviors Programs).
a)  Beneficiaries have access to EBAP accounts under Medicaid Reform as follows:
i.  Individuals who are enrolled in a Medicaid Reform plan and who have
participated in a state defined activity that promotes healthy behavior and thus
have a positive balance;
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ii.  Individuals who no longer are enrolled in a Medicaid Reform plan (either due to
loss of eligibility or change of eligibility to an eligibility group not authorized to
participate; or transition to a Healthy Behaviors programs through their MMA
plan) but who have a positive balance in their account;
iii.  Regardless of the reason for the loss of eligibility to participate in the
demonstration, an individual participating in EBAP may retain access to any
earned funds for a maximum of one year, except in the instance of termination of
the demonstration.  Upon implementation of the MMA program, recipients who
have accrued credits under Medicaid Reform will be able to access those credits
for up to one year; and,
iv.  If an individual subsequently regains Medicaid eligibility, the enrollee will be
eligible to participate in the EBAP and earn additional credits until the MMA
program has been implemented in the regional where the individual resides.  
b)  Beneficiaries have access to Healthy Behaviors accounts under MMA as follows:
Managed care plans will not be required to transfer earned credits or rewards or
provide access to earned credits or rewards if a beneficiary changes managed care
plans.  For beneficiaries who lose Medicaid eligibility, plans will be required to
maintain record of the credits for 180 days and re-instate earned credits or rewards if
the beneficiary re-establishes eligibility and re-enrolls with the plan within 180 days.
67.  Federal Financial Participation (FFP) Under Both Medicaid reform and MMA
Program. The state shall claim FFP at the time the enhanced benefits credits are utilized
by an enrollee to purchase an approved product, supply, or service.
68.  Enhanced Benefits Account Program Contracts Under Medicaid Reform. The state
shall provide CMS a copy of any procurement document to administer the EBAP. In
addition, the state will provide the CMS Regional Office a copy of the contract for
approval, to administer the EBAP.  At a minimum, the contract will specify the scope of
work, duration of the contract, and the amount of contract.
69. Effective and Efficient Administration of the Enhanced Benefits Accounts Program
Under Medicaid Reform and the Healthy Behaviors programs under the MMA
Program. The state will submit documentation related to EBAP and Healthy Behaviors
eligibility activities, respective earnings for each activity, eligible health related
expenditures and access to account information in the Annual Report and Quarterly
Reports as discussed in Section XVI, General Reporting Requirements.
XIII.  ADDITIONAL PROGRAMS
70.  Transition of two current 1915(b)(3) programs and one state plan program.
On January 1, 2014 programs currently authorized under Florida’s Section 1915(b)
Medicaid Managed Care Waiver, will expire and instead be authorized under this
demonstration.  These programs will be available in all parts of the state.  
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a.  The Healthy Start Program  - authorized as 1915(b)(3) services under Florida’s
Section 1915(b) Medicaid Managed Care Waiver;
b.  The Program for All Inclusive Care for Children (a component of the Children’s
Medical Services Network) – authorized as 1915(b)(3) services under Florida’s
Section 1915(b) Medicaid Managed Care Waiver; and
c.  The Comprehensive Hemophilia Program authorized as state plan covered service
under Florida’s Section 1915(b) Medicaid Managed Care Waiver.
71. Healthy Start Program. The Healthy Start program is available statewide for eligible
Medicaid recipients. The Healthy Start program is comprised of the following two
components:
(a)  MomCare: includes outreach and case management services for all women
presumptively eligible and eligible for Medicaid under SOBRA. The MomCare
component is mandatory for these women as long as they are eligible for Medicaid,
and offers initial outreach to facilitate enrollment with a qualified prenatal care
provider for early and continuous health care, Healthy Start prenatal risk screening
and WIC services.  Recipients may disenroll at any time.  In addition, the MomCare
component assists and facilitates the provision of any additional identified needs of
the Medicaid recipient, including referral to community resources, family planning
services, Medicaid coverage for the infant and the need to select a primary care
physician for the infant.
(b)  Healthy Start Coordinated System of Care: includes outreach and case
management services for eligible pregnant women and children identified at risk
through the Healthy Start program.  These services are voluntary and are available for
all Medicaid pregnant women and children up to the age of 3 who are identified to be
at risk for a poor birth outcome, poor health and poor developmental outcomes.  The
services vary, dependent on need and may include: information, education and
referral on identified risks, assessment, case coordination, childbirth education,
parenting education, tobacco cessation, breastfeeding education, nutritional
counseling and psychosocial counseling.  The goal of this component is to increase
the intensity and duration of service to Healthy Start beneficiaries.
72.  Program for All Inclusive Care for Children (Children’s Medical Services Network).
Participation in the PACC program is voluntary.  The PACC program provides the
following pediatric palliative care support services to children enrolled in the CMS
Network who have been diagnosed with potentially life-limiting conditions and referred
by their primary care provider (PCP).
a)  Support Counseling – Face-to-face support counseling for child and family unit in the
home, school or hospice facility, provided by a licensed therapist with documented
pediatric training and experience.  
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b)  Expressive Therapies – Music, art, and play therapies relating to the care and
treatment of the child and provided by registered or board certified providers with
pediatric training and experience.
c)  Respite Support – Inpatient respite in a licensed hospice facility or in-home respite
for patients who require justified supervision and care provided by RN, LPN, or HHA
with pediatric experience. This service is limited to 168 hours per year.
d)  Hospice Nursing Services – Assessment, pain and symptom management, and in-home nursing when the experience, skill, and knowledge of a trained pediatric
hospice nurse is justified.
e)  Personal Care – This service is to be used when a hospice trained provider is justified
and requires specialized experience, skill, and knowledge to benefit the child who is
experiencing pain or emotional trauma due to their medical condition.
f)  Pain and Symptom Management – Consultation provided by a CMS Network
approved physician with experience and training in pediatric pain and symptom
management.
Bereavement and volunteer services are provided but are not reimbursable services.
73. Comprehensive Hemophilia Disease Management Program. The Medicaid
Comprehensive Hemophilia Management program operates statewide as a specialized
service whereby recipients who have a diagnosis of hemophilia or von Willebrand
disease and are enrolled in the fee-for-service (FFS) system, the MediPass program (the
MediPass program will be terminated with the implementation of the MMA program),
FFS PSN, capitated PSN or an HMO, are required to obtain pharmaceutical services and
products related to factor replacement therapy from one of the two contracted vendors.
In addition to product distribution, the program provides pharmacy benefit management,
direct beneficiary contact, personalized education, enhanced monitoring, and direct
support of beneficiaries in the event of hospitalization, at no additional cost to the state.
Enrollees have access to a registered nurse and licensed pharmacist 24 hours a day,
seven days a week.  The enrollees also have access to medical care and treatment
through their usual and customary networks, with no restrictions on services or
providers, and receive pharmacy products other than those related to factor replacement
therapy via the usual and customary networks without restriction, as well.
The populations enrolled in the program have a diagnosis of hemophilia, are currently
Medicaid eligible, receive prescribed drugs from the therapeutic MOF Factor IX, and
MOE-Antihemophilic Factors, Corifact (MOC therapeutic class), Stimate (P2B
therapeutic class), and other therapeutic classes identified by the Agency as treatment for
hemophilia or von Willebrand; are in the FFS system, MediPass program (the MediPass
program will be terminated upon implementation of the MMA program), FFS PSN,
HMO or capitated PSN. Medicaid-Medicare eligible individuals may voluntarily enroll in
the program.
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XIV.  LOW INCOME POOL
74.  Low Income Pool Definition.  The LIP provides government support for the safety net
providers that furnish uncompensated care to the Medicaid, underinsured and uninsured
populations.  The LIP is also designed to establish new, or enhance existing, innovative
programs that meaningfully enhance the quality of care and the health of low income
populations.  Initiatives must broadly drive from the three overarching goals of CMS’
Three-Part Aim as described in paragraph 84(a).  The LIP consists of a capped annual
allotment of $1 billion total computable for each year of the demonstration extension.
75.  Availability of Low Income Pool Funds. Funds in the LIP are available to the state on
an annual basis subject to any penalties that are assessed by CMS for the failure to meet
milestones as discussed in Section XV “Low Income Pool Milestones”.   Funds available
through the LIP may be reduced to recoup payments made to providers that are
determined by CMS to have been made in excess of allowable costs.  Any necessary
recoupments will be achieved through a reduction of FFP claimed against LIP payments
or through disallowance.  Available funds not distributed in a DY may be rolled over to
the next DY.  All LIP funds must be expended by June 30, 2014.  LIP dollars that are lost
as a result of penalties or recoupment are surrendered by the state and not recoverable.
76.  LIP Reimbursement and Funding Methodology.  LIP permissible expenditures
defining state authorized expenditures from and entities eligible to receive LIP
reimbursement are defined in the Reimbursement and Funding Methodology document
dated October 2012.  This document limits LIP payments to allowable costs incurred by
providers and requires the state to reconcile LIP payments to auditable costs.  CMS is
currently working with the state on reconciliations for DY 4.  The state submitted to CMS
Reconciliations for DY 5 on May 31, 2013.
CMS has determined that payments made to providers in DY 1-3 are in excess of
allowable costs; therefore, the state is required to return the federal portion of
$104,351,578 total computable expenditures claimed in excess of allowable cost and/or
in excess of applicable cost limits.  This will be achieved through a reduction of the
amount available to be claimed under the pool by $104 million the first year of the state’s
intended renewal period in the event the demonstration is renewed or, by issuing a
disallowance to the state.
If the reconciliations for DY 4 identify LIP payments in excess of allowable cost
consistent with paragraph 75 and the Reimbursement and Funding Methodology
document implementing the LIP, the state must modify the Reimbursement and Funding
Methodology applicable to DY 6 to ensure that payments under the LIP are consistent
with the LIP goals and that providers will not receive payments that exceed their costs
utilizing the cost reconciliation information to inform payment methodology
modifications.  CMS will also work with the state to identify modifications to the
Methodology to address any cost documentation or audit processes necessary to fully
meet cost reconciliation requirements.  Any changes required by CMS will be applied
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prospectively to payments and audits for the next demonstration year.  The state may
claim LIP payments based on the existing Methodology during the 60 day reconciliation
finalization period.  Claims after that period can only be made on the modified final
approved Reimbursement and Funding Methodology approved by March 1, 2012.
Changes to the Reimbursement and Funding Methodology document requested by the
state must be approved by CMS and are only approved for one demonstration year.
DY 4 and 5 reconciliation results will be reflected in the Reimbursement and Funding
Methodology documents for DY 9 and 10.  If the final reconciliations for DY 4 and 5
result in a finding that payments were made in excess of cost, the Reimbursement and
Funding Methodology must be further modified to ensure that payments in the next
demonstration year will not result in payments in excess of allowable cost, particularly
methodologies that provide payments to providers that have received payments during
any prior demonstration year in excess of allowable costs as defined in paragraph 75 and
the Reimbursement and Funding Methodology.  Any required modifications to the DY 7
annual Reimbursement and Funding Methodology document must be approved by CMS
before FFP will be made available for the next demonstration year’s LIP payments.
The state shall by February 1 of each year of the demonstration, submit a protocol to
ensure that the payment methodologies for distributing LIP funds to providers supports
the goals of the LIP as described in paragraph 74 and that providers receiving LIP
payments do not receive payments in excess of their cost of providing services.  FFP is
not available for LIP payments until the protocol is finalized and approved by CMS.
77.  Low Income Pool Permissible Expenditures. Funds from the LIP may be used for
health care costs (medical care costs or premiums) that would be within the definition of
medical assistance in Section 1905(a) of the Act.  These health care costs may be
incurred by the state, by hospitals, clinics, or by other provider types to furnish medical
care for the uninsured and underinsured for which compensation is not available from
other payors, including other federal or state programs.  Such costs may include premium
payments, payments for provider access systems (PAS) and insurance products for such
services provided to otherwise uninsured individuals, as agreed upon by the state and
CMS. These health care costs may also include costs for Medicaid services that exceed
Medicaid payments (after all other Title XIX payments are made, including
disproportionate share hospital payments).
78.  Low Income Pool Expenditures - Non-Qualified Aliens.  LIP funds cannot be used for
costs associated with the provisions of health care to non-qualified aliens.
79. Low Income Pool Permissible Expenditures 10 percent Sub Cap.  Up to 10 percent of
the capped annual allotment of the LIP funds may be used for hospital expenditures other
than payments to providers for the provision of health care services to an uninsured or
underinsured individual.  Payments from this sub-cap may be used for the improvement
or continuation of specialty health care services that benefit the uninsured and
underinsured, such as capacity building and infrastructure, hospital trauma services,
hospital neonatal services, rural hospital services, pediatric hospital services, teaching or
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specialty hospital services, or safety net providers.  The reimbursement methodologies
for these expenditures and the non-federal share of funding for such expenditures will be
defined in the Reimbursement and Funding Methodology Document as discussed in
paragraph 76.
80.  Low Income Pool Permissible Hospital Expenditures. Hospital cost expenditures from
the LIP will be paid at cost and are further defined in the Reimbursement and Funding
Methodology document utilizing methodologies from the CMS-2552 cost report plus
mutually agreed upon additional costs.  The state agrees that it shall not receive FFP for
Medicaid and LIP payments to hospitals in excess of cost.
81.  Low Income Pool Permissible Non-Hospital Based Expenditures. To ensure services
are paid at cost, the Reimbursement and Funding Methodology document defines the cost
reporting strategies required to support non-hospital based LIP expenditures.
82. Permissible Sources of Funding Criteria. Sources of non-Federal funding must be
compliant with section 1903(w) of the Act and applicable regulations. Federal funds
received from other federal programs (unless expressly authorized by federal statute to be
used for matching purposes) shall be impermissible.
XV.  LOW INCOME POOL MILESTONES
83.  Aggregate LIP Funding. At the beginning of each DY, $1 billion in LIP funds will be
available to the state.  These amounts will be reduced by any milestone penalties that are
assessed by CMS.  Two tiers of milestones, as described in paragraph’s 84 and 85, must
be met for the state and facilities to have access to 100 percent of the annual LIP funds.
Funds not distributed in a DY may be rolled over to the next DY.
84.  Tier - One Milestone. Tier-one milestones are defined as follows:
a)  Development and implementation of a state initiative that requires Florida to allocate
$50 million in total LIP funding in DY 7 and DY 8 to establish new, or enhance
existing, innovative programs that meaningfully enhance the quality of care and the
health of low income populations. Initiatives must broadly drive from the three
overarching goals of CMS’ Three-Part Aim.
i.  Better care for individuals including safety, effectiveness, patient centeredness,
timeliness, efficiency, and equity;
ii.  Better health for populations by addressing areas such as poor nutrition, physical
inactivity, and substance abuse; and,
iii.  Reducing per-capita costs.
Expenditures incurred under this program must be permissible LIP expenditures as
defined under Section, Low Income Pool.  The state will utilize DY 6 to develop the
program.  The program must be implemented with LIP funds allocated and
expenditures incurred in DYs 7 and 8.  
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b)  Timely submission of all hospital, FQHC, and County Health Department LIP
reconciliations in the format required per the LIP Reimbursement and Funding
Methodology protocol.  The state shall submit to CMS, within 30 days from the date
of formal approval of the waiver extension request, a schedule for the completion of
the LIP Provider Access Systems (PAS) reconciliations for the 3-year extension
period. CMS will provide comments to the state on the reconciliation schedules
within 30 days.  The state will submit the final reconciliation schedule to CMS within
60 days of the original submission date.
c)  Timely submission of all demonstration deliverables as described in the STCs
including the submission of Quarterly and Annual Reports.
d)  Development and submission of an annual “Milestone Statistics and Findings Report”
and a “Primary Care and Alternative Delivery Systems Expenditure Report”. Within
60 days following the acceptance of the terms and conditions, the state must submit
templates for these reports and anticipated timelines for report submissions.
e)  Timely submission of all other reporting requirements under Sections XVI, General
reporting Requirements, XIX, Evaluation of the Demonstration and XX,
Measurement of Quality of Access to Care and Improvement.
f)  CMS will assess penalties on an annual basis for the state’s failure to meet tier-one
milestones or components of tier-one milestones.  Penalties of $6 million will be
assessed annually for each tier-one milestone that is not met. Penalties will be
determined by December 31
st
of each DY and assessed to the state in the following
DY.  LIP dollars that are lost as a result of tier-one penalties not being met, are
surrendered by the state.
85. Tier-Two Milestones. Tier-two milestones initiatives must drive from the three
overarching goals of the Three-Part Aim as described in paragraph 84(a).  The initiatives
will focus specifically on: infrastructure development; innovation and redesign; and
population focused improvement.  Participating facilities must implement new, or
enhance existing, health care initiatives, investments, or activities with the goal of
meaningfully improving the quality of care and the health of populations served
(including low income populations) and meet established hospital specific targets, to
receive 100 percent of allocated LIP funding.  Tier-two milestones apply to facilities that
receive the largest annual allocations of LIP funds and put at risk 3.5 percent of each of
these facility’s annual LIP allocation.  The milestones apply to the 15 hospitals which are
allocated the largest annual amounts in LIP funding.  If the total annual LIP funds
allocated for the 15 hospitals, do not total at least $700 million, the population of
hospitals must be expanded until $700 million is reached.
Hospitals will be required to select and participate in 3 initiatives.  Depending on the
breadth of health care activities undertaken by a facility, CMS may consider exceptions
to the requirement that three initiatives must be implemented.    
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Once a facility is identified as a top 15 hospital, it must continue to achieve milestones to
receive future DY LIP funding regardless of whether it drops out of the top 15 category.
Exceptions to this requirement may be considered by CMS.  Hospitals entering the top 15
category in future DYs will be subject to timelines similar to program planning/success
and execution timelines.
A top 15 hospital cannot select quality improvement initiatives under which it is currently
receiving or may be eligible to receive other federal dollars unless the LIP outcome goals
are enhanced over previously established targets.
Within 90 days following the acceptance of the terms and conditions, CMS and the state
will, through a collaborative process, finalize the plan and procedures including the
specific health care initiatives, investments, and activities, and the applicable standards,
measures, and evaluation measures and protocols that will allow for the implementation
and monitoring of tier-two milestones and evaluation of the impact of these initiatives.
The specific metrics chosen should support the measurements required in paragraph
110(a)(vii-ix).  CMS must approve the final plan and procedures which will require that
tier-two facilities receiving funds in SFY 2011-2012 must submit its milestone plan by
March 31, 2012, including baseline data and outcome targets, to meet their DY 6 (SFY
2011-2012) tier-two milestone.
Hospital initiatives that can be implemented under tier-two milestones, which are tied to
the Three-Part Aim, include the following and are drawn from recent demonstration
experiences:
a)  Infrastructure Development – Investments in technology, tools and human resources
that will strengthen the organization’s ability to serve its population and continuously
improve its services.  Examples of such initiatives are:
i.  Increase in Primary Care capacity including residency programs and externships;
ii.  Introduction of Telemedicine;
iii.  Enhanced Interpretation Services and Culturally Competent Care; and,
iv.  Enhanced Performance Improvement Capacity;
b)  Innovation and Redesign – Investments in new and innovative models of care
delivery that have the potential to make significant, demonstrated improvements in
patient experience, cost, and disease management.  Examples of such initiatives are:
i.  Expansion of Medical Homes;
ii.  Primary Care Redesign; and,
iii.  Redesign for Efficiencies (e.g. Program Integrity).
c)  Population-focused Improvement – Investments in enhancing care delivery for the 5 –
10 highest burden (morbidity, cost, prevalence, etc) conditions/services present for
the population in question. Examples of such initiatives are:
i.  Improved Diabetes Care Management and Outcomes;
ii.  Improved Chronic Care Management and Outcomes;
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Approval period: December 16, 2011, through June 30, 2014
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iii.  Reduction of Readmissions;
iv.  Improved Quality (with attention to reliability and effectiveness, and targeted to
particular conditions or high-burden problems);
v.  Emergency Department Utilization and Diversion;
vi.  Reductions in Elective Preterm Births; and,
vii.  PICU and NICU Quality and Safety (e.g. pediatric catheter associated blood
stream infection rates).
Between January 1 2012 and March 31, 2012, the tier-two milestone facility’s
receiving funds in SFY 2011-2012 must submit a plan/program including baseline
data and outcome targets, to meet their DY 6 (SFY 2011-2012) tier-two milestone.
Subsequent year LIP funds allocated to these hospitals will be made available based
upon the successful execution of the facilities targeted health care initiatives.
The state must assess a penalty of 3.5 percent of a facility’s annual LIP allocation for
failing to meet tier-two milestones or components of tier-two milestones.  Penalties, if
applicable, will be determined by December 31
st
of each DY (with the exception of
DY 6, which will be determined by March 31, 2012) and assessed to the facility in the
remaining 6 months of the same DY. LIP dollars that are not paid out as a result of
tier-two milestones not being met, are surrendered by the facility and state.
XVI.  GENERAL REPORTING REQUIREMENTS
86.  General Financial Requirements. The state must comply with all general financial
requirements set forth in Section XVII.
87.  Reporting Requirements Relating to Budget Neutrality. The state must comply with
all reporting requirements set forth in Section XVIII.
88.  Managed Care Data Requirements. All managed care organizations shall maintain an
information system that collects, analyzes, integrates and reports data as set forth at 42
CFR 438.242.  This system shall include encounter data that can be reported in a
standardized format.  Encounter data requirements shall include the following:
a)  Encounter Data (Health Plan Responsibilities) – The health plan must collect,
maintain, validate and submit data for services furnished to enrollees as stipulated by
the state in its contracts with the health plans.
b)  Encounter Data (State Responsibilities) - The state shall, in addition, develop
mechanisms for the collection, reporting, and analysis of these, as well as a process to
validate that each plan’s encounter data are timely, complete and accurate.  The state
will take appropriate actions to identify and correct deficiencies identified in the
collection of encounter data.  The state shall have contractual provisions in place to
impose financial penalties if accurate data are not submitted in a timely fashion.
Additionally, the state shall contract with its EQRO to validate encounter data
through medical record review.  
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013
c)  Encounter Data Validation Study for New Capitated Managed Care Plans - If the
state contracts with new managed care organizations, the state shall conduct a
validation study 18 months after the effective date of the contract to determine
completeness and accuracy of encounter data.  The initial study shall include
validation through a sample of medical records of demonstration enrollees.
d)  Submission of Encounter Data to CMS - The state shall submit encounter data to the
Medicaid Statistical Information System (MSIS) and when required T-MSIS
(Transformed MSIS) as is consistent with federal law.  The state must assure that
encounter data maintained at managed care organizations can be linked with
eligibility files maintained at the state.
89. Monitoring Calls. During the implementation phase of the MMA program, CMS will
schedule weekly implementation calls that will continue until at least 60 days after the
last region is implemented. The state and CMS shall jointly develop the agenda for the
calls.
a)  CMS will schedule monthly conference calls with the state.  The purpose of these
calls is to discuss any significant actual or anticipated developments affecting the
demonstration.  Areas to be addressed include but are not limited to, health plan
operations (such as contract amendments, rate certifications, plans withdrawing or
entering the demonstration), health care delivery, enrollment, quality of care, access,
benefit packages including EPSDT, dental care, the Enhanced Benefits Account
Program (until MMA program is implemented), Healthy Behaviors Programs, choice
counseling activities, audits, lawsuits, financial reporting related to budget neutrality
issues, health plan financial performance that is relevant to the demonstration,
progress on evaluations, state legislative developments, and any demonstration
amendments, concept papers or state plan amendments the state is considering
submitting that impact the demonstration.  The state and CMS shall discuss quarterly
expenditure reports submitted by the state for purposes of monitoring budget
neutrality.  CMS shall update the state on any amendments or concept papers under
review as well as federal policies and issues that may affect any aspect of the
demonstration.  The state and CMS shall jointly develop the agenda for the calls.
90.  Quarterly Reports. The state must submit progress reports, to include the items outlined
below (see also Attachment A), no later than 60 days following the end of each quarter.
The intent of these reports is to present the state’s analysis and the status of the various
operational areas under the demonstration.  These quarterly reports must include, but are
not limited to:
a)  An updated budget neutrality monitoring spreadsheet including enrollment data,
member month data, and expenditure data in the format provided by CMS.  As
described in STC 94(d)(iv), reports on the state’s progress in developing the
necessary CMS-64 reporting system changes to accommodate the MMA program,
should the 1115 demonstration be renewed;
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Amended June 14, 2013
b)  A discussion of events occurring during the quarter, or anticipated to occur in the near
future, that affect health care delivery, including but not limited to: approval and
contracting with new plans; geographic expansion; benefits; enrollment and
disenrollment; quality of care; access; pertinent legislative or litigation activity; and
other operational issues;
A discussion of network adequacy reporting from medical and dental plans including
customer service reporting; average speed of answer at the plans and call
abandonment rates; summary of capitated managed care plan and FFS PSNs appeals
for the quarter including overturn rate and any trends identified; enrollee complaints
and grievance reports to determine any trends; and summary analysis of the managed
care plans critical incident report which includes, but is not limited to, incidents of
abuse, neglect and exploitation;
c)  Action plans for addressing any policy, administrative, or budget issues identified;
d)  State efforts related to the collection and verification of encounter data, and
utilization data;
e)  Medical Loss Ratio data pertaining to Medicaid plan operations in demonstration
counties;
f)  Enrollment data disaggregated by plan and by the following specifications: eligibility
category, TANF and SSI, total number of enrollees; market share; and percentage
change in enrollment by plan. In addition, the state will provide a summary of
voluntary and mandatory selection rates and disenrollment data;
g)  Choice of plans and capacity of plans participating in the Reform and MMA Program
counties including the number of beneficiaries who made an affirmative choice verses
being auto-enrolled into a plan;
h)  Efforts to promote alignment and integration with Medicare for Medicare-Medicaid
eligible individuals, including the number of participants who are in an MMA plan
and an affiliated Medicare Advantage plan.
i)  Documentation of the efforts to promote full and timely access to medical, vision,
hearing, dental, mental health, and other care and services covered under the EPSDT
benefit for children, as well as services required by the Florida Department of
Children and Families for foster care children.
j)  Low Income Pool activities and associated expenditures;
k)  Activities related to choice counseling including efforts to improve health literacy and
the methods used to obtain public input including recipient focus groups;
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Approval period: December 16, 2011, through June 30, 2014
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l)  Participation rates in the Enhanced Benefits Account Program until implementation
of the MMA program and the Healthy Behaviors Programs after MMA
implementation. This shall include: participation levels; summary of activities and the
associated expenditures; number of accounts established including active participants
and individuals who continue to retain access to funds in an account but no longer
actively participate; estimated quarterly deposits in accounts, and expenditures from
the account;
m)  Status of managed care plan performance, initiatives and activities, as measured by
HEDIS, CAHPs and other quality metrics;
n)  Description of the implementation progress of expanding managed care, challenges
encountered, and how the challenges were addressed;
o)  Progress toward the demonstration goals; and,
p)  Evaluation activities including the contracting status with an independent evaluator.
91.  Annual Report.  The state must submit an annual report no later than 120 days after the
close of each DY.  Within 30 days of receipt of comments from CMS, a final annual
report must be submitted.
The report must documenting accomplishments, project status, quantitative and case
study findings, interim evaluation findings, utilization data, and policy and administrative
difficulties in the operation of the demonstration.  This report must also contain a
discussion of the items that must be included in the quarterly reports required under
paragraph 90 and include a section that provides qualitative and quantitative data that
describes the impact the LIP has had on the rate of uninsurance in Florida since
implementation of the demonstration.  In addition, the annual report must address the
following items.
a)  Yearly enrollment reports must be included for all demonstration enrollees for each
demonstration year (DY) that include the member months, as required to evaluate
compliance with the budget neutral agreement, and the total number of unique
enrollees within the DY.
b)  Pursuant to STC 118, the state must report on the implementation and effectiveness of
the updated Comprehensive Quality Strategy as it impacts the demonstration.
c)   Managed Care Delivery System.  The state must document accomplishments, project
status, quantitative and case study findings, interim evaluation findings, utilization
data, progress on implementing cost containment initiatives and policy and
administrative difficulties in the operation of the demonstration.  The state must
provide the CAHPS survey, outcomes of any focused studies conducted and what the
state intends to do with the results of the focused study, outcomes of any reviews or
interviews related to measurement of any disparities by racial or ethnic groups,
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
annual summary of network adequacy by plan including an assessment of the
provider network pre and post implementation and managed care plan compliance
with provider 24/7 availability, summary of outcomes of any on-site reviews
including EQRO, financial, or other types of reviews conducted by the state or a
contractor of the state, summary of performance improvement projects being
conducted by the state and any outcomes associated with the interventions, outcomes
of performance measure.
d)  Medicare-Medicaid Eligible Enrollees. The state must report on the efforts to
promote alignment and integration with Medicare for dual-eligible individuals.
e)  Children including foster care children.  The state must report on the efforts to
promote full and timely access to medical, vision, hearing, dental, mental health and
other care and services covered under the EPSDT benefits for children, as well as
services required by the Florida Department of Children and Families for foster care
children.
f)  Managed Care Expansion. The state must report on the implementation progress,
challenges encountered, and how the challenges were addressed, as specified in
section X, Consumer Protections.
g)  Evaluation. The state must report on the contracting status with an independent
evaluator.
92.  Transition Plan. The state is required to prepare and incrementally revise, a Transition
Plan consistent with the provisions of the Affordable Care Act (ACA) for individuals
enrolled in the demonstration, including how the state plans to coordinate the transition
of these individuals to a coverage option available under the ACA without interruption
in coverage to the maximum extent possible.  The state must submit a draft final report
to CMS by July 1, 2012, with progress updates included in each quarterly report
required by paragraph 90.  On June 24, 2012, the state notified CMS that a transition
was not applicable to the demonstration.
XVII.  GENERAL FINANCIAL REQUIREMENTS
93.  Quarterly Expenditure Reports.  The state must provide quarterly expenditure reports
using Form CMS-64 to report total expenditures for services provided through this
demonstration under section 1115 authority that are subject to budget neutrality.  This
project is approved for expenditures applicable to services rendered during the
demonstration period. CMS shall provide FFP for allowable demonstration expenditures
only as long as they do not exceed the pre-defined limits on the costs incurred as
specified in Section XIV.
94.  Reporting Expenditures Subject to the Budget Neutrality Expenditure Limit.  All
expenditures for health care services for demonstration participants and categories, as
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
described in section (d), are subject to the budget neutrality agreement.  The following
describes the reporting of expenditures subject to the budget agreement:
a)  Tracking Expenditures.  In order to track expenditures, the state must report
demonstration expenditures through the Medicaid and Children's Health Insurance
Program Budget and Expenditure System (MBES/CBES), following routine CMS-64
reporting instructions outlined in Section 2500 of the state Medicaid Manual.  All
demonstration expenditures claimed under the authority of Title XIX of the Act and
subject to the budget neutrality expenditure limit must be reported each quarter on
separate Forms CMS-64.9 Waiver and/or 64.9P Waiver, identified by the
demonstration project number (11-W-00206/4) assigned by CMS, including the
project number extension which indicates the demonstration year (DY) in which
services were rendered or for which capitation payments were paid.  In addition to
reporting through the CMS-64 the state’s expenditures on dental care, the state must
also report on spending on dental care through the health plans.
b)  Cost Settlements.  For monitoring purposes, cost settlements attributable to the
demonstration must be recorded on the appropriate prior period adjustment schedules
(Form CMS-64.9P Waiver) for the Summary Sheet Line 10B, in lieu of Lines 9 and
10C.  For any cost settlement not attributable to this demonstration, the adjustments
should be reported as otherwise instructed in the state Medicaid Manual.
c)  Pharmacy Rebates.  The state may propose a methodology for assigning a portion of
pharmacy rebates to the demonstration in a way that reasonably reflects the actual
rebate-eligible pharmacy utilization of the demonstration population, and which
reasonably identifies pharmacy rebate amounts with DYs. Use of the methodology is
subject to the approval in advance by the CMS Regional Office, and changes to the
methodology must also be approved in advance by the Regional Office.  The portion
of pharmacy rebates assigned to the demonstration using the approved methodology
will be reported on the appropriate Forms CMS-64.9 Waiver for the demonstration
and not on any other CMS-64.9 form (to avoid double counting).  Each rebate amount
must be distributed as state and Federal revenue consistent with the federal matching
rates under which the claim was paid.
d)  Use of Waiver Forms.  For each DY, a waiver Form CMS-64.9 Waiver and/or 64.9P
Waiver must be submitted each quarter, using the waiver names listed below.  The
waiver names designate the waiver forms in the MBES/CBES system to report Title
XIX expenditures associated with the demonstration.
i.  Through June 30, 2014, the current MEGs (MEG 1: SSI, MEG 2: TANF,
MEG 3: Low Income Pool) with the following currently approved population
mappings will be utilized for the CMS-64 reporting purposes.  Demonstration
Populations 1 and 7 represent Reform counties and include all enrolled mandatory
and voluntary participants.  Populations 2 through 5 represent non-reform
counties and include all individuals who would be mandatory participants if
Reform was effective in that county.
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(A)  :Demonstration Population 1 (MEG 1) – (Aged/Disabled): Aged and
disabled demonstration enrollees.
(B)  Demonstration Population 2 (MEG 1) – (FMR-SSI+DsEldw/oMcare):
Aged and disabled individuals without Medicare in non-Reform counties
who would be required to enroll in the demonstration.
(C)  Demonstration Population 3 (MEG 2) – (FMR-TANF): Individuals
qualifying under TANF in non-Reform counties who would be required to
enroll in the demonstration.
(D)  Demonstration Population 4 (MEG 2) – (FMR-SOBRA/FC): Individuals
qualifying under SOBRA or Foster Care in non-Reform counties who would
be required to enroll in the demonstration.
(E)  Demonstration Population 5 (MEG 1) – (FMR->65): Individuals 65 and
older in non-Reform counties who would be required to enroll in the
demonstration.
(F)  Demonstration Population 6 (MEG 3) – (Low Income Pool):
Demonstration expenditures allowed under the Low Income Pool.
(G)  Demonstration Population 7 (MEG 2) – (TANF & related grp): TANF
demonstration enrollees.
ii.  Beginning no earlier than January 1, 2014, expenditures associated with
mandatory and voluntary MMA enrollees will be reported using the currently
approved classification as defined in (i) above.
iii.  If the 1115 Research and Demonstration Waiver is renewed, the CMS-64 will
reflect the expenditures for statewide MMA populations, including those
attributable to MMA voluntary populations.  The following names and definitions
will be utilized for the CMS-64 reporting purposes:
(A)  MEG 1: SSI
(B)  MEG 2: TANF
(C)  MEG 3: Low Income Pool
At this time, the CMS-64 will reflect the expenditures for statewide MMA
populations, including those attributable to MMA voluntary populations.
iv.  Progress Reports.  The state must submit quarterly progress reports on its
progress in developing new programming logic to accommodate the necessary
CMS-64 reporting system changes, should the 1115 demonstration be renewed.
e)  Excluded Services. The following services are excluded from the demonstration:
i.  ID Waiver (HCBS Waiver Services);
ii.  Home Safe Net (Behavioral Services) until the MMA program is implemented;
iii.  Behavioral Health Overlays Services (Services Only) until the MMA program is
implemented;  
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iv.  ICF/IID Institutional Services;
v.  Family & Supported Living Waiver Services;
vi.  Katie Beckett Model Waiver Services;
vii.  Brain & Spinal Cord Waiver Services; and
viii.  School Based Admin Claiming.
f)  Mandated Increase in Physician Payment Rates in 2013 and 2014.  Section 1202 of
the Health Care and Education Reconciliation Act of 2010 (Pub. Law 110-152)
requires state Medicaid programs to pay physicians for primary care services at rates
that are no less than what Medicare pays, for services furnished in 2013 and
2014.  The federal government provides a federal medical assistance of 100 percent
for claimed the amount by which the minimum payment exceeds the rates paid for
those services as of July 1, 2009.  The state may exclude from the budget neutrality
test for this demonstration the portion of the increase for which the federal
government pays 100 percent.  These amounts should be reported on the base forms
CMS-64.9, 64.21, or 64.21U (or their “P” counterparts), and not on any waiver form.
g)  Cost-Sharing Adjustments.  Applicable cost-sharing contributions from enrollees that
are collected by the state from enrollees under the demonstration must be reported to
CMS each quarter on Form CMS-64 Summary Sheet line 9D, columns A and B. In
order to assure that these collections are properly credited to the demonstration,
premium and cost-sharing collections (both total computable and federal share)
should also be reported separately by DY on Form CMS-64 Narrative.  In the
calculation of expenditures subject to the budget neutrality expenditure limit,
premium collections applicable to demonstration populations will be offset against
expenditures.  These section 1115 premium collections will be included as a manual
adjustment (decrease) to the demonstration’s actual expenditures on a quarterly basis.
h)  Title XIX Administrative Costs.  Administrative costs will not be included in the
budget neutrality agreement, but the state must separately track and report additional
administrative costs that are directly attributable to the demonstration.  All
administrative costs must be identified on the Forms CMS-64.10 Waiver and/or
64.10P Waiver.
i)  Claiming Period.  All claims for expenditures subject to the budget neutrality
agreement (including any cost settlements) must be made within 2 years after the
calendar quarter in which the state made the expenditures.  Furthermore, all claims
for services during the demonstration period (including any cost settlements) must be
made within 2 years after the conclusion or termination of the demonstration.  During
the latter 2-year period, the state must continue to identify separately net expenditures
related to dates of service during the operation of the demonstration on the CMS-64
waiver forms in order to properly account for these expenditures in determining
budget neutrality.
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95.  Reporting Member Months.  The following describes the reporting of member months
for demonstration Populations.
a)  For the purpose of calculating the budget neutrality expenditure limit and for other
purposes, the state must provide to CMS, as part of the Quarterly Report required
under paragraph 90, the actual number of eligible member months for the three MEGs
described in paragraph 106 the state must provide CMS, upon request, eligible
member months by population as defined in paragraph 94(d).  The state must submit
a statement accompanying the Quarterly Report which certifies the accuracy of this
information.  To permit full recognition of “in-process” eligibility, reported counts of
member months may be subject to revision.
b)  The term "eligible member/months" refers to the number of months in which persons
are eligible to receive services.  For example, a person who is eligible for 3 months
contributes 3 eligible member months to the total.  Two individuals who are eligible
for 2 months each contribute 2 eligible member months to the total, for a total of 4
eligible member/months.
c)  Starting January 1, 2014, the state must begin reporting separate member month totals
for mandatory and voluntary individuals enrolled in MMA that are not already
represented in the member month reporting in place prior to that date.  The member
months must be subtotaled according to the MEGs defined in subparagraph (d)(i)
above.
96.  Standard Medicaid Funding Process.  The standard Medicaid funding process must be
used during the demonstration. The state must estimate matchable demonstration
expenditures (total computable and federal share) subject to the budget neutrality
expenditure limit and separately report these expenditures by quarter for each federal
fiscal year (FFY) on the Form CMS-37 (narrative section) for both the Medical
Assistance Payments (MAP) and state and Local Administrative Costs (ADM).  CMS
shall make federal funds available based upon the state’s estimate, as approved by CMS.
Within 30 days after the end of each quarter, the state must submit the Form CMS-64
quarterly Medicaid expenditure report, showing Medicaid expenditures made in the
quarter just ended.  CMS shall reconcile expenditures reported on the Form CMS-64 with
federal funding previously made available to the state, and include the reconciling
adjustment in the finalization of the grant award to the state.
97.  Extent of FFP. Subject to CMS approval of the source(s) of the non-federal share of
funding, CMS shall provide FFP at the applicable federal matching rates for the
following,  subject to the limits described in Section XVI:
a)  Administrative costs associated with the administration of  the demonstration;
b)  Net expenditures and prior period adjustments, made under approved Expenditure
Authorities granted through section 1115(a)(2) of the Act, with dates of service
during the operation of the demonstration;
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Amended June 14, 2013   
c)  Net expenditures and prior period adjustments for Medicaid Reform Plan premiums
paid to managed care entities and fee for service coverage options;
d)  Net Expenditures associated with the LIP, as described in Section XIII; and,
e)  Net Expenditures associated with the EBAP.
Pursuant to standard Medicaid financing rules, FFP is excluded for payments with respect
to care or services for any individual who is an inmate of a public institution (except as a
patient in a medical institution) pursuant to the payment exclusion in paragraph (A)
following section 1905(a)(29) of the Act.
In addition, pursuant to standard Medicaid financing rules, FFP is excluded for payments
with respect to care or services for any individual who has not attained 65 year of age and
who is a patient in an institution for mental diseases pursuant to the payment exclusion in
paragraph (B) following section 1905(a)(29) of the Act, except as provided in section
1905(a)(16) for inpatient psychiatric services for individuals under age 21.
98. Sources of Non-Federal Share.  The state provides assurance that the matching non-federal share of funds for the demonstration is state/local monies. The state further
assures that such funds shall not be used as the match for any other federal grant or
contract, except as permitted by law.  All sources of non-federal funding must be
compliant with section 1903(w) of the Act and applicable regulations.  In addition, all
sources of the non-federal share of funding are subject to CMS approval.
a)  CMS may review at any time the sources of the non-federal share of funding for the
demonstration.  The state agrees that all funding sources deemed unacceptable by
CMS shall be addressed within the time frames set by CMS.
b)  The state shall provide information to CMS regarding all sources of the non-federal
share of funding for any amendments that impact the financial status of the program.
c)  The state assures that all health care related taxes comport with section 1903(w) of
the Act and all other applicable federal statutory and regulatory provisions, as well as
the approved Medicaid state plan.
99.  State Certification of Funding Conditions. The state must certify that the following
conditions for non-federal share of the demonstration expenditures are met:
a)  Units of government, including governmentally-operated health care providers, may
certify that state or local tax dollars have been expended as the non-federal share of
funds under the demonstration;
b)  To the extent the state utilizes certified public expenditures (CPEs) as the funding
mechanism for Title XIX (or under section 1115 authority) payments, CMS must
approve a cost reimbursement methodology.  This methodology must include a
detailed explanation of the process by which the state would identify those costs
eligible under Title XIX (or under section 1115 authority) for purposes of certifying
public expenditures;
c)  To the extent the state utilizes CPEs as the funding mechanism to claim federal match
for payments under the demonstration, governmental entities to which general
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Amended June 14, 2013   
revenue funds are appropriated must certify to the state the amount of such tax
revenue (state or local) used to satisfy demonstration expenditures.  The entities that
incurred the cost must also provide cost documentation to support the state’s claim
for federal match;
d)  The state may use intergovernmental transfers to the extent that such funds are
derived from state or local tax revenues and are transferred by units of government
within the state.  Any transfers from governmentally-operated health care providers
must be made in an amount not to exceed the non-federal share of Title XIX
payments; and,
e)  Under all circumstances, health care providers must retain 100 percent of the
reimbursement amounts claimed by the state as demonstration expenditures.
Moreover, no pre-arranged agreements (contractual or otherwise) may exist between
the health care providers and the state government to return and/or redirect any
portion of the Medicaid payments.  This confirmation of Medicaid payment retention
is made with the understanding that payments that are the normal operating expenses
of conducting business (such as payments related to taxes, including health care
provider-related taxes, fees, and business relationships with governments that are
unrelated to Medicaid and in which there is no connection to Medicaid payments) are
not considered returning and/or redirecting a Medicaid payment.
100.  MSIS Data Submission. The state shall submit its MSIS data electronically to CMS in
accordance with CMS requirements and timeliness standards, including the required
transition to T-MSIS.
101.  Monitoring the Demonstration. The state must provide CMS with information to
effectively monitor the demonstration, upon request, in a reasonable timeframe.
102.  Program Integrity. The state must have processes in place to ensure that there is no
duplication of federal funding for any aspect of the demonstration.
XVIII.  MONITORING BUDGET NEUTRALITY
The following describes the method by which budget neutrality will be assured under the
demonstration. The demonstration will be subject to a limit on the amount of federal Title XIX
funding that the state may receive on selected Medicaid expenditures during the demonstration
period. Paragraphs 103 and 104 specify the two independent financial caps on the amount of
federal Title XIX funding that the state may receive on expenditures subject to the budget
neutrality limit as defined in paragraph 94.  Federal financial payments for the Medicaid Reform
aspects of the demonstration are limited by a Per Member Per Month (PMPM) method cap and
the payments for the LIP aspects are limited by an aggregate cap.
103.  Budget Neutrality Limit for the LIP. The LIP amount is capped at $1 billion total
computable for each DY. Funds not distributed in a DY may be rolled over to the next
DY. The federal share of the annual $1 billion total computable is the maximum
amount of FFP that the state may receive during the extension period for the types of
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Amended June 14, 2013   
Medicaid expenditures for the LIP. For each DY, the federal share will be calculated
using the FMAP rate(s) applicable to that year.
104.  Limit on PMPM Title XIX Funding. The state shall be subject to a limit on the
amount of federal Title XIX funding that the state may receive on the Medicaid and
demonstration expenditures identified in paragraph 94 during the approval period of the
demonstration.  The limit is determined using a PMPM method. The budget neutrality
targets are set on a yearly basis with a cumulative budget neutrality limit for the length
of the entire demonstration.  All data supplied by the state to CMS is subject to review
and audit, and if found to be inaccurate, will result in a modified budget neutrality limit.
CMS’ assessment of the state’s compliance with these limits will be done using the
CMS-64 Report from the MBES/CBES System.
105.  Risk. The state shall be at risk for the per capita cost of demonstration enrollees under
this budget neutrality agreement, but not for the number of demonstration enrollees.
By providing FFP for all demonstration enrollees, the state will not be at risk for
changing economic conditions which impact enrollment levels.  However, by placing
the state at risk for the per capita costs for demonstration enrollees, CMS assures that
the federal demonstration expenditures do not exceed the level of expenditures that
would have occurred had there been no demonstration.
106.  Budget Neutrality Expenditure Limit. The following describes the method for
calculating the budget neutrality expenditure limit for the demonstration.
Demonstration expenditures are defined under the following Medicaid Eligibility
Groups (MEGs) as referenced in paragraph 94(d):
a)  MEG 1: SSI
b)  MEG 2: TANF
c)  MEG 3 : Low Income Pool
For the purpose of calculating the overall PMPM expenditure limit for the demonstration,
separate budget estimates will be calculated for each year on a demonstration year (DY)
basis. The annual estimates will then be added together to obtain an expenditure estimate
for the entire demonstration period. The federal share of this estimate will represent the
maximum amount of FFP that the state may receive during the extension period for the
types of Medicaid expenditures for the SSI and TANF MEGs.  Budget neutrality
calculations for both with and without waiver expenditures are applied on a statewide
basis.  For each DY, the federal share will be calculated using the FMAP rate(s)
applicable to that year.  For the purpose of monitoring budget neutrality, the $1 billion in
annual LIP expenditures is considered as both with and without waiver expenditures.
a)  Projecting Service Expenditures - Each yearly estimate of Medicaid Reform service
expenditures will be the cost projections for the SSI and TANF MEGs in sub-paragraph (b) below.  The annual budget estimate for each MEG will be the product
of the projected PMPM cost for the MEG, times the actual number of eligible
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Amended June 14, 2013   
member months as reported to CMS by the state under the guidelines set forth in
paragraph 95.
b)  Projected PMPM Cost - The PMPM costs for each MEG used to calculate the annual
budget neutrality expenditure limit for this demonstration are specified below.  The
PMPM estimates for SSI MEG and TANF MEG are applied to the member months
reported based on the standards in place as of June 2013.  The PMPM estimates for
SSI MEG and TANF MEG are applied to the member months reported for MMA
enrollees, discussed in paragraph 95(c).
Demonstration
Year
SSI MEG  Trend
Rate
TANF
MEG
Trend
Rate
SSI
MEG
MMA
TANF
MEG
MMA
DY 1 (SFY
2007)
$ 948.79  8.0%  $199.48  8.0%   
DY 2 (SFY
2008)
$1,024.69  8.0%  $215.44  8.0%   
DY 3 (SFY
2009)
$1,106.67  8.0%  $232.68  8.0%   
DY 4 (SFY
2010)
$1,195.20  8.0%  $251.29  8.0%   
DY 5 (SFY
2011)
$1,290.82  8.0%  $271.39  8.0%   
DY 6 (SFY
2012)
$1,356.65  5.1%  $285.77  5.3%   
DY 7 (SFY
2013)
$1,425.84  5.1%  $300.92  5.3%   
DY 8 (SFY
2014)
$1,498.56  5.1%  $316.87  5.3%  $294.01  $583.64
107.  How the Limit will be Applied. The limits as defined in paragraphs 103 through 106
will apply to the actual expenditures for the demonstration, as reported by the state
under Section XVIII.  If at the end of the demonstration period the budget neutrality
provision has been exceeded, the excess federal funds will be returned to CMS.  There
will be no new limit placed on the FFP that the state can claim for expenditures for
recipients and program categories not listed.
108.  Impermissible DSH, Taxes or Donations.  CMS reserves the right to adjust the budget
neutrality ceiling to be consistent with enforcement of impermissible provider
payments, health care related taxes, new federal statutes, or policy interpretations
implemented through state Medicaid Director letters, other memoranda, or regulations.
CMS reserves the right to make adjustments to the budget neutrality cap if any health
care related tax that was in effect during the base year, or provider related donation that
occurred during the base year, is determined by CMS to be in violation of the provider
donation and health care related tax provisions of 1903(w) of the Social Security Act.
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Adjustments to annual budget targets will reflect the phase out of impermissible
provider payments by law or regulation, where applicable.
109.  PMPM Expenditure Review.  CMS shall enforce budget neutrality over the life of the
demonstration, rather than on an annual basis.  However, no later than 6 months after
the end of each demonstration year, the state will calculate an annual expenditure target
for the completed year and report it to CMS as part of the reporting guidelines in
paragraph 91.  This amount will be compared with the actual FFP claimed by the state
under budget neutrality.  Using the schedule below as a guide for the PCCM budget
limit, if the state exceeds the cumulative target, they shall submit a corrective action
plan to CMS for approval.  The state will subsequently implement the approved
program.
Year    Cumulative target definition          Percentage
Year 6  Years 1 through 6 combined budget neutrality cap plus  1 percent
Year 7  Years 1 through 7 combined budget neutrality cap plus  0.5 percent
Year 8  Years 1 through 8 combined budget neutrality cap plus  0 percent
XIX.   EVALUATION OF THE DEMONSTRATION
110.  Submission of Draft Evaluation Design Update.  The state must submit to CMS for
approval, within 120 days of the approval date of the MMA amendment, a draft
evaluation design update that builds and improves upon the evaluation design that was
approved by CMS on October 31, 2012.  At a minimum, the draft design must include a
discussion of the goals, objectives and specific testable hypotheses, including those that
focus specifically on target populations for the demonstration, and more generally on
beneficiaries, providers, plans, market areas and public expenditures.  The analysis plan
must cover all elements in paragraph 112). The updated design should be described in
sufficient detail to determine that it is scientifically rigorous. The data strategy must be
thoroughly documented.  The updated design should accommodate and reflect the
staggered implementation of the MMA program to produce more reliable estimates of
program impacts.  The design should describe how the evaluation and reporting will
develop and be maintained to assure its scientific rigor and completion. In summary,
the demonstration evaluation will meet all standards of leading academic institutions
and academic journal peer review, as appropriate for each aspect of the evaluation,
including standards for the evaluation design, conduct, interpretation and reporting of
findings.  Among the characteristics of rigor that will be met are the use of best
available data; controls for and reporting of the limitations of data and their effects on
results; and the generalizability of results.
The updated design must describe the state’s process to contract with an independent
evaluator, ensuring no conflict of interest.
The design, including the budget and adequacy of approach, to assure the evaluation
meets the requirements of 112(a), is subject to CMS approval. The budget and
approach must be adequate to support the scale and rigor reflected in the paragraph
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above.  The rigor also described above also applies as appropriate throughout Sections
XIX and XX.
111.  Cooperation with Federal Evaluators. Should HHS undertake an evaluation of any
component of the demonstration, the State shall cooperate fully with CMS or the
evaluator selected by HHS. The state shall submit the required data to HHS or its
contractor
112.  Evaluation Design.
a)  Domains of Focus – The state must propose as least one research question that it will
investigate within each of the domains listed below.  The research questions should
focus on processes and outcomes that relate to the CMS Three-Part Aim of better
care, better health, and reducing costs.  With respect to domains vii, viii, and ix, the
state must propose two research questions under each domain (one each from Tier-One and Tier-Two milestones).
i.  The effect of managed care on access to care, quality and efficiency of care, and
the cost of care;
ii.  The effect of customized benefit plans on beneficiaries’ choice of plans, access to
care, or quality of care;
iii.  Participation in the Enhanced Benefits Account Program (EBAP) and the MMA
plans’ Healthy Behaviors programs (upon implementation of the MMA program)
and its effect on participant behavior or health status;
iv.  The impact of the demonstration as a deterrent against Medicaid fraud and abuse;
v.  The effect of LIP funding on the number of uninsured and underinsured, and rate
of uninsurance;
vi.  The effect of LIP funding on disparities in the provision of healthcare services,
both geographically and by population groups;
vii.  The impact of Tier-One and Tier-Two milestone initiatives on access to care and
quality of care (including safety, effectiveness, patient centeredness, timeliness,
efficiency, and equity);
viii.  The impact of Tier-One and Tier-Two milestone initiatives on population health;
ix.  The impact of Tier-One and Tier-Two milestone initiatives on per-capita costs
(including Medicaid, uninsured, and underinsured populations) and the cost-effectiveness of care;
x.  The effect of having separate managed care programs for acute care and LTC
services on access to care, care coordination, quality, efficiency of care, and the
cost of care.  Baseline data to evaluate this domain will be collected prior to June
30, 2014;
xi.  The effect of having separate managed care programs for acute care and LTC
services on the demonstration’s impact as a deterrent against Medicaid fraud and
abuse. Baseline data to evaluate this domain will be collected prior to June 30,
2014;
xii.  The effect of transitioning the EBAP program from direct state operation to the
MMA plans’ Healthy Behaviors programs; and,  
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Amended June 14, 2013   
xiii.  The impact of efforts to align with Medicare and improving beneficiary
experiences and outcomes for dual-eligible individuals.
b)  Measures. The draft evaluation design must discuss the outcome measures that shall
be used in evaluating the impact of the demonstration during the period of approval,
including:
i.  A description of each outcome measure selected, including clearly defined
numerators and denominators, and National Quality Forum (NQF) numbers (as
applicable);
ii.  The measure steward;
iii.  The baseline value for each measure;
iv.  The sampling methodology for assessing these outcomes; and
v.  The methods of data collection.
c)  Sources of Measures.  CMS recommends that the state use measures from nationally-recognized sources and those from national measures sets (including CMS’s Core Set
of Health Care Quality Measures for Children in Medicaid and CHIP, and the Initial
Core Set of Health Care Quality Measures for Medicaid-Eligible Adults).
d)  The evaluation design must also discuss the data sources used, including the use of
Medicaid encounter data, enrollment data, EHR data, and consumer and provider
surveys.  The draft evaluation design must include a detailed analysis plan that
describes how the effects of the demonstration shall be isolated from other initiatives
occurring in the state.  The evaluation designs proposed for each question may
include analysis at the beneficiary, provider, and aggregate program level, as
appropriate, and include population stratifications to the extent feasible, for further
depth and to glean potential non-equivalent effects on different sub-groups.
113.  Final Evaluation Design and Implementation. CMS shall provide comments on the
draft design and the draft MMA evaluation strategy within 60 days of receipt, and the
state shall submit a final design within 60 days of receipt of CMS’ comments.  The
state must implement the evaluation design and submit its progress in each of the
quarterly and annual progress reports.  The state must submit to CMS a draft of the
evaluation final report by October 31, 2014.  The state must submit the final evaluation
report within 60 days after receipt of CMS’ comments.
The state must submit to CMS a draft of the evaluation final report by October 31,
2014. The final report must include the following:
a)  An executive summary;
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
b)  A description of the demonstration, including programmatic goals, interventions
implemented, and resulting impact of these interventions;
c)  A summary of the evaluation design employed, including hypotheses, study design,
measures, data sources, and analyses;
d)  A description of the population included in the evaluation (by age, gender,
race/ethnicity, etc.);
e)  Final evaluation findings, including a discussion of the findings (interpretation and
policy context); and
f)  Successes, challenges, and lessons learned.
XX.  MEASUREMENT OF QUALITY OF CARE AND ACCESS TO CARE
IMPROVEMENT
114.  External Quality Review (EQR).  The state is required to meet all requirements for
external quality review (EQR) found in 42 C.F.R. Part 438, subpart E. In addition to
routine encounter data validation processes that take place at the MCO/PIHP and state
level, the state must maintain its contract with its external quality review organization
(EQRO) to require the independent validation of encounter data for all MCOs and
PIHPs at a minimum of once every three years.
The state should generally have available its final EQR technical report to CMS and the
public, in a format compliant with Section 508 of the Rehabilitation Act (29 U.S.C. §
794d), by April 30th of each year, for data collected within the prior 15 months.  This
submission timeframe will align with the collection and annual reporting on managed
care data by the Secretary of Health and Human Services each September 30th, which
is a requirement under the Affordable Care Act [Sec. 2701 (d)(2)].
115.  Consumer Health Plan Report Cards.  On an annual basis, the state must create and
make readily available to beneficiaries, providers, and other interested stakeholders, a
health plan report card, in a format compliant with Section 508 of the Rehabilitation
Act (29 U.S.C. § 794d), that is based on performance data on each health plan included
in the annual EQR technical report.   Each health plan report card must be posted on the
state’s website and present an easily understandable summary of quality, access, and
timeliness regarding the performance of each participating health plan.  The report
cards must also address the performance of subcontracted dental plans.
116.  Performance Improvement Projects (PIPs).  The state must require each health plan
to commit to improving care in the following focus areas, which have the significant
potential for achieving the demonstration’s goals of improving patient care, population
health, and reducing per capita Medicaid expenditure.  
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
a)  A PIP combining a focus on improving prenatal care and well-child visits in
the first 15 months;
b)  A PIP focused on preventive dental care for children;
c)  An administrative PIP, topic of which must be approved by the state; and
d)  A choice of PIP in one of the following topic areas:
a.  Population health issues (such as diabetes, hypertension and asthma)
within a specific geographic area that have been identified as in need
of improvement;
b.  Integrating primary care and behavioral health; and
c.  Reducing preventable readmissions .
Each PIP must be conducted in accordance with 42 C.F.R. §§ 438.358 and 438.240.
The state must incorporate these PIP requirements into its MMA managed care plan
contracts upon implementation of the MMA program.
117.  Measurement Activities.  The state must ensure that each participating health plan is
accountable for metrics on quality and access, including measures to track progress in
identified quality improvement focus areas, measures to track quality broadly, and
measures to track access.  The state must set performance targets that equal or exceed
the 75
th
percentile national Medicaid performance level.
The state must collect data and information on dental care utilization rates, the CMS
Medicaid and CHIP adult and child core measures, and must align with other existing
federal measure sets where possible to ensure ongoing monitoring of individual well-being and plan performance.  The state will use this information in ongoing monitoring
and quality improvement efforts, in addition to quality reporting efforts.
118.  Comprehensive State Quality Strategy.  The state shall adopt and implement a
comprehensive and holistic, continuous quality improvement strategy that focuses on
all aspects of quality improvement in Medicaid, including FFS populations; FFS PSNs ;
and capitated managed care plans, including Medicaid Reform, and the MMA program,
and managed long term services and supports.  The Comprehensive Quality Strategy
(CQS) shall meet all the requirements of 42 CFR 438 Subparts D and E and must
include section 1915(c) HCBS waivers’ corrective action plan quality components.
a)  The CQS must also address the following elements:
i.  The state’s goals for improvement, identified through claims and encounter data,
quality metrics and expenditure data.  The goals should align with the three part
aim but should be more specific in identifying specific pathways for the state to
achieve these goals.
ii.  The associated interventions for improvement in the goals.
iii.  The specific quality metrics for measuring improvement in the goals.  The metrics
should be aligned with the Medicaid and CHIP adult and child core measures, and
should also align with other existing Medicare and Medicaid federal measure sets
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
where possible.  The metrics should go beyond HEDIS and CAHPS data, and
should reflect cost of care.
iv.  Metrics should be measured at the following levels of aggregation: the state
Medicaid agency, each health plan, and each direct health services provider.  The
state will work with CMS to further define what types of metrics will be measured
for direct service providers.
v.  The specific methodology for determining benchmark and target performance on
these metrics for each aggregated level identified above (state, plan and provider).
vi.  Performance improvement accountability – i.e., the state must determine if the
current plans for financial incentives adequately align with the specific goals and
targeted performance, and whether enhancements to these incentives are
necessary (increased or restructured financial incentives, in-kind incentives,
contract management, etc.).  The state must present the findings of the
determination to CMS.
vii.  Specific metrics related to each population covered by the Medicaid program.
HCBS performance measures, consistent with the corrective action plan, in the
areas of: level of care determinations, person-centered service planning process,
outcome of person-centered goals, health and welfare, and assuring there are
qualified providers and appropriate HCBS settings.   
viii.  Monitoring and evaluation.  This should include specific plans for continuous
quality improvement, which includes transparency of performance on metrics and
structured learning, and also a rigorous and independent evaluation of the
demonstration, as described in STC 110. The evaluation should reflect all the
programs covered by the CQS as mentioned above.
ix.  HIV evaluation. The state will evaluate, in accordance with the rigor described in
STC 110, the HIV population to determine if there are better health outcomes for
HIV positive beneficiaries in the HIV specialty plan as compared to in a MMA
health plan. The state will also evaluate medication adherence and improved care
and care coordination as a result of being enrolled in the HIV specialty plan.
b)  The CQS should include a timeline that considers metric development and
specification, contract amendments, data submission and review, incentive
disbursement (if available), and the re-basing of performance data.
c)  The CQS must include state Medicaid agency and any contracted service providers’
responsibilities, including managed care entities, and providers enrolled in the state’s
FFS program.  The state Medicaid agency must retain ultimate authority and
accountability for ensuring the quality of and overseeing the operations of the
program.  The CQS must include distinctive components for discovery, remediation,
and improvement.
d)  The first draft of this CQS is due to CMS no later than 120 days following the
approval of this amendment/renewal. CMS will review this draft and provide
feedback to the state. The state must revise and resubmit the CQS to CMS for
approval within 45 days of receipt of CMS comment.  The state must revise (and
submit to CMS for review and approval) their CQS whenever significant changes are
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
made to the associated Medicaid programs and the content of the CQS. Revisions to
the CQS must be submitted to CMS for review and approval within 90 days of
approval of the amendment authorizing the implementation of MMAP.
Any further revisions must be submitted accordingly:
i.  Modifications to the CQS due to changes in the Medicaid operating authorities
must be submitted concurrent with the proposed changes to the operating
authority (e.g., state plan or waiver amendments or waiver renewals); and/or
ii.  Changes to an existing, approved CQS due to fundamental changes to the CQS
must be submitted for review and approval to CMS no later than 60 days prior to
the contractual implementation of such changes.  If the changes to the CQS do not
impact any provider contracts, the revisions to the CQS may be submitted to CMS
no later than 60 days following the changes.
e)  The state must solicit for and obtain the input of beneficiaries, the Medical Care
Advisory Committee (MCAC) as set forth in STC 43, and other stakeholders in the
development of its CQS and make the initial CQS, as well as any significant
revisions, available for public comment prior to implementation.  Pursuant to STC 91,
Annual Report, the state must also provide CMS with annual reports on the
implementation and effectiveness of their CQS as it impacts the demonstration.
f)  As required by 42 C.F.R. §438.360(b)(4), the state must identify in the CQS any
standards for which the EQRO will use information from private accreditation
reviews to complete the compliance review portion of EQR for participating MCOs
or PIHPs. The state must, by means of a crosswalk included in the CQS, set forth
each standard that the state deems as duplicative to those addressed under
accreditation and explain its rationale for why the standards are duplicative.
g)  Upon approval by CMS, the state will finalize the CQS to be fully compliant with
Section 508 of the Rehabilitation Act (29 U.S.C. § 794d).
XXI.  SCHEDULE OF STATE DELIVERABLES
Date  Deliverable  STC Reference
60 days following
the end of the
quarter
Quarterly Progress Reports   Section XVI, STC 90
120 days following
the end of the
demonstration year
Annual Report  Section XVI, STC 91
30 days following
the end of the
quarter
Quarterly Expenditure
Reports
Section XVII, STC 93
90 days following
the award of the
Managed Care Policies   Section III, STC 17 (a), (b),
(d), and (e)
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Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013   
demonstration
October 31, 2013  MMA Program
Implementation Schedule
Section VIII, STC 35(a)
30 days in advance
of implementation
in each region
Implementation regional
reports
Section VIII, STC 35.f)
7 months following
the end of each
quarter
Quarterly Medical Loss
Ratio Reporting by the
capitated plans for
Demonstration Counties
Section III, STC 17 (c)
30 days following
award of the
demonstration
Premium Assistance
Transition Plan
Section XVI, STC 92
July 1, 2012   ACA Transition Plan   Section XVI, STC 92
60 days following
acceptance of the
STCs
LIP Reconciliations for DYs
1, 2, and 3
Section XIV, STC 76
30 days following
acceptance of the
STCs
LIP Reconciliation
Schedule for DYs 6, 7, and
8
Section XV, STC 84(b)
60 days following
acceptance of the
STCs
Templates for LIP
Milestone and Expenditure
Reports
Section XV, STC 84(d)
120 days following
the award of the
MMA amendment
Draft Evaluation Design   Section XIX, STC 110
120 days following
the award of the
MMA amendment
Draft Comprehensive
Quality Strategy
Section XX, STC 118
Various  LIP Milestone Deliverables   Section XV, STCs 84 and 85
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Amended June 14, 2013
ATTACHMENT A
Under paragraph 90, the state is required to submit quarterly progress reports to CMS.  The
purpose of the quarterly report is to inform CMS of significant demonstration activity from the
time of approval through completion of the demonstration.  The reports are due to CMS 60 days
after the end of each quarter.
The following report guidelines are intended as a framework showing the broad categories of
information to be reported and can be modified when agreed upon by CMS and the state. A
complete quarterly progress report must include all items described in paragraph 90 and an
updated budget neutrality monitoring workbook.
NARRATIVE REPORT FORMAT
Title Line One – Florida Managed Medical Assistance Program
Title Line Two - Section 1115 Quarterly Report
Demonstration/Quarter Reporting Period:
Example:
Demonstration Year:  6 (7/1/2011 – 6/30/2012)
Federal Fiscal Quarter:  4/2011 (7/1/2011 – 9/30/2011)
Introduction
Please provide information describing the goal of the demonstration, what it does, and key dates
of approval/operation. (This should be the same for each report.)
Enrollment Information
Please complete the following table that outlines all enrollment activity under the demonstration.
The state should indicate “N/A” where appropriate. If there was no activity under a particular
enrollment category, the state should indicate that by “0”.  Enrollment counts should be person
counts.
Demonstration Populations
(as hard coded in the Form CMS-64)
Total as
of end of
Current
Quarter
Voluntary
Disenrolled in
Current
Quarter
Involuntary
Disenrolled in
Current
Quarter
Population 1 - Aged/Disabled      
Population 2 - FMR-SSI+DsEldw/oMcare
Population 3 - FMR-TANF  
Population 4 - FMR-SOBRA/FC     
Population 5 - FMR->65     
Population 7 - TANF & related grp       
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Amended June 14, 2013   
After January 1, 2014, expenditures for statewide
MMA populations, including those attributable to
MMA voluntary populations are to be included in
this reporting.
Outreach/Innovative Activities
Summarize outreach activities including but not limited to Choice Counseling, MMA
implementation outreach and educational tour and/or promising practices for the current quarter.
Operational/Policy Developments/Issues
Identify all significant program developments/issues/problems that have occurred in the current
quarter, including but not limited to: approval and contracting with new plans; benefit changes;
legislative activity; Healthy Behaviors program benefits by health plan and participation rates;
network adequacy including customer service reporting; complaints, grievances and appeals;
reporting on managed care plans critical incidents, efforts to promote alignment or integration for
Medicare-Medicaid eligible individuals.
Consumer Issues
Provide a summary of the types of complaints or problems consumers identified about the
program in the current quarter.  Include any trends discovered, the resolution of complaints, and
any actions taken or to be taken to prevent other occurrences.  Identify and address any appeals
related to medical necessity under the EPSDT benefit.
Quality Assurance /Monitoring Activities
Identify any quality assurance/monitoring activity in the current quarter, including but not
limited to MCAC recommendations, PIP progress and Consumer Health Plan Report Cards.
Demonstration Evaluation
Discuss progress of evaluation design and planning.
Financial/Budget Neutrality Development/Issues
Identify all significant developments/issues/problems with financial accounting, budget
neutrality, and Form CMS-64 reporting for the current quarter. Identify the state’s actions to
address these issues.
Enclosures/Attachments
Identify by Title any attachments along with a brief description of what information the
document contains.
State Contact(s)
Identify individuals by name, Title, phone, fax, and address that CMS may contact should any
questions arise.
Florida Managed Medical Assistance Program      Page 62 of 62
Approval period: December 16, 2011, through June 30, 2014
Amended June 14, 2013
Date Submitted to CMS