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Subject to par. (i), the department shall create and implement a program to reimburse participating hospitals and health care systems for intensive care coordination services provided to recipients of Medical Assistance under this subchapter who are not enrolled in coverage under Medicare, 42 USC 1395 et seq.
To apply to participate in the reimbursement program under this subsection, a hospital or health care system shall submit to the department a description of its intensive care coordination program that includes all of the following: 1. A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients. 2. The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months. 3. A description of the hospital’s or health care system’s intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers. 4. A statement that the hospital or health care system will provide to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care: a. Discharge instructions and contacts for following up on care and treatment. b. Referral information. c. Appointment scheduling. d. Medication instructions. e. Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization. f. Information about other health and social resources, such as transportation and housing. 5. A statement that the hospital or health care system agrees to share information with the state-designated entity for health information exchange or with another appropriate data-sharing mechanism. For Medical Assistance recipients who are enrolled in managed care, a hospital or health care system shall agree to share, at the request of the managed care organization, applicable discharge instructions, current medication information, and care plan information as permitted by s. 146.816 (2) with the managed care organization in which the recipients are enrolled. The hospital or health care system may satisfy the requirement under this subdivision to share information with a managed care organization by providing the information to the state-designated entity for health information exchange or by providing the information to the managed care organization using another appropriate information-sharing mechanism agreed upon by the hospital or health care system and the managed care organization. 6. The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or a managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.
A statement that the hospital or health care system will use emergency department utilization data to identify recipients of Medical Assistance to receive intensive care coordination to reduce use of the emergency department by those Medical Assistance recipients.
The method the hospital or health care system uses to identify for intensive care coordination a Medical Assistance recipient who uses the emergency department frequently. The hospital or health care system shall specify how it defines frequent emergency department use and may use criteria such as whether a recipient of Medical Assistance visits the emergency room 3 or more times within 30 days, 6 or more times within 90 days, or 7 or more times within 12 months.
A description of the hospital’s or health care system’s intensive care coordination team consisting of health care providers other than solely physicians, such as nurses; social workers, case managers, or care coordinators; behavioral health specialists; and schedulers.
A statement that the hospital or health care system will provide to a Medical Assistance recipient enrolled in intensive care coordination through the hospital or health care system all of the following, as appropriate to his or her care: a. Discharge instructions and contacts for following up on care and treatment. b. Referral information. c. Appointment scheduling. d. Medication instructions. e. Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization. f. Information about other health and social resources, such as transportation and housing.
Discharge instructions and contacts for following up on care and treatment.
Referral information.
Appointment scheduling.
Medication instructions.
Intensive care coordination by a social worker, case manager, nurse, or care coordinator to connect the Medical Assistance recipient to a primary care provider or to a managed care organization.
Information about other health and social resources, such as transportation and housing.
A statement that the hospital or health care system agrees to share information with the state-designated entity for health information exchange or with another appropriate data-sharing mechanism. For Medical Assistance recipients who are enrolled in managed care, a hospital or health care system shall agree to share, at the request of the managed care organization, applicable discharge instructions, current medication information, and care plan information as permitted by s. 146.816 (2) with the managed care organization in which the recipients are enrolled. The hospital or health care system may satisfy the requirement under this subdivision to share information with a managed care organization by providing the information to the state-designated entity for health information exchange or by providing the information to the managed care organization using another appropriate information-sharing mechanism agreed upon by the hospital or health care system and the managed care organization.
The outcomes intended to result from intensive care coordination by the hospital or health care system. Outcomes for a Medical Assistance recipient during a 6-month or 12-month period may include successful connection to primary care or a managed care organization as evidenced by 2 or 3 primary care appointments, successful connection to behavioral health resources and alcohol and other drug abuse resources, as needed, or a decrease in use of the emergency room.
The department shall do all of the following: 1. Encourage, but not require, any hospital or health care system that seeks to apply to participate in the reimbursement program under this subsection to collaborate with any managed care organization with which it has an agreement to provide services to Medical Assistance recipients. The department may not limit patient populations eligible to participate in the intensive care coordination program under this subsection to either those individuals enrolled in managed care to receive Medical Assistance services or those individuals currently receiving Medical Assistance services on a fee-for-service basis. The department may not deny a hospital or health care system applicant for the reimbursement program under this subsection solely because the applicant does not have an agreement to implement an intensive care coordination program with a managed care organization. 2. Respond to the hospital or health care system indicating whether additional information is required to evaluate the application for the reimbursement program under this subsection. 3. After consulting with hospitals, health care systems, and other providers, develop uniform outcome measures to use in determining the efficacy of the program. 4. If the hospital or health care system is selected for the reimbursement program under this subsection, provide a description of the process for enrolling Medical Assistance recipients in intensive care coordination for reimbursement. 5. If the department does not receive a proposal for the reimbursement program under this subsection, solicit proposals for the reimbursement program under this subsection from other health care providers under s. 146.81 (1).
Encourage, but not require, any hospital or health care system that seeks to apply to participate in the reimbursement program under this subsection to collaborate with any managed care organization with which it has an agreement to provide services to Medical Assistance recipients. The department may not limit patient populations eligible to participate in the intensive care coordination program under this subsection to either those individuals enrolled in managed care to receive Medical Assistance services or those individuals currently receiving Medical Assistance services on a fee-for-service basis. The department may not deny a hospital or health care system applicant for the reimbursement program under this subsection solely because the applicant does not have an agreement to implement an intensive care coordination program with a managed care organization.
Respond to the hospital or health care system indicating whether additional information is required to evaluate the application for the reimbursement program under this subsection.
After consulting with hospitals, health care systems, and other providers, develop uniform outcome measures to use in determining the efficacy of the program.
If the hospital or health care system is selected for the reimbursement program under this subsection, provide a description of the process for enrolling Medical Assistance recipients in intensive care coordination for reimbursement.
If the department does not receive a proposal for the reimbursement program under this subsection, solicit proposals for the reimbursement program under this subsection from other health care providers under s. 146.81 (1).
The department shall provide as reimbursement for intensive care coordination to participants in the program under this subsection $250 initially for each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the hospital or health care system enrolls in intensive care coordination. The initial enrollment for each recipient lasts for 6 months, and if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population, the participant receives an additional $250 for each enrollee at the end of the 6 months. The program participant may enroll each Medical Assistance recipient in one additional 6-month period for an additional $250 per enrollee initial reimbursement payment and $250 per enrollee at the end of the additional 6-month period if the participant demonstrates progress in reducing emergency department visits for at least half of its enrollee population. The department shall pay no more than $1,500,000 cumulatively in each fiscal year from all funding sources for reimbursements under this paragraph.
Annually, each hospital and health care system that is participating in the reimbursement program under this subsection shall submit a report to the department containing all of the following: 1. The number of Medical Assistance recipients served by intensive care coordination. 2. For each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the number of emergency department visits for a period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination. 3. Any demonstrated outcomes, as specified by the department under par. (c) 3., for Medical Assistance recipients. 4. Any other information required by the department.
The number of Medical Assistance recipients served by intensive care coordination.
For each Medical Assistance recipient who is not enrolled in coverage under Medicare, 42 USC 1395 et seq., the number of emergency department visits for a period before enrollment of that recipient in intensive care coordination and the number of emergency department visits for the same recipient during the same period after enrollment in intensive care coordination.
Any demonstrated outcomes, as specified by the department under par. (c) 3., for Medical Assistance recipients.
Any other information required by the department.
For each hospital or health care system eligible for the reimbursement program under this subsection, the department shall calculate the costs saved to the Medical Assistance program by avoiding emergency department visits by subtracting the sum of reimbursements made under par. (d) to the participant from the sum of costs of visits to the emergency department as reported under par. (e) 2. that were expected to occur without intensive care coordination but did not because of enrollment in the program under this subsection. If the result of the calculation is positive in the first 6 months of the recipient’s enrollment in the program under this subsection, the department shall distribute 25 percent of the amount saved to the hospital, health care system, or managed care organization subject to pars. (g) and (i). If the result of the calculation is positive after 12 months of the recipient’s enrollment in the program under this subsection, the department shall distribute a share of the savings to the hospital, health care system, or managed care organization such that the total amount of shared savings payments made equals half of the savings for the entire 12-month period, subject to pars. (g) and (i).
If a hospital or health care system participating in the program under this subsection provides services to Medical Assistance recipients enrolled in managed care, the department shall make any payment under the program under this subsection under par. (d) or (f) to the managed care organization with which the hospital or health care system has an agreement to provide services to Medical Assistance recipients. The managed care organization shall pass the payments made under pars. (d) and (f) on to the hospital or health care system no later than 30 days after receiving the payment from the department. The department shall make payments under pars. (d) and (f) to a hospital or health care system that provides services to Medical Assistance recipients who are not enrolled in managed care directly to the hospital or health care system.
No later than 24 months after the date on which the first hospital or health care system is able to enroll individuals in the intensive care coordination program under this subsection, the department shall submit a report to the joint committee on finance summarizing the information reported under par. (e) including the costs saved by avoiding emergency department visits as calculated under par. (f).
The department shall seek any necessary approval from the federal department of health and human services to implement the program under this subsection. If the federal department of health and human services disapproves the request for approval, the department may implement the reimbursement under par. (d), the savings distribution under par. (f), or both or any part of the program under this subsection.
If the federal department of health and human services does not disapprove a request for approval under par. (i) or if federal approval is not required, the department shall implement at least 2 pilot programs under this subsection by the later of September 1, 2018, or the date that is 30 days after the date of federal approval, if approval is needed.