(1) ELIGIBLE PLANS.—Services in the Medicaid managed care program shall be provided by eligible plans. A provider service network must be capable of providing all covered services to a mandatory Medicaid managed care enrollee or may limit the provision of services to a specific target population based on the age, chronic disease state, or medical condition of the enrollee to whom the network will provide services. A specialty provider service network must be capable of coordinating care and delivering or arranging for the delivery of all covered services to the target population. A provider service network may partner with an insurer licensed under chapter 627 or a health maintenance organization licensed under chapter 641 to meet the requirements of a Medicaid contract.
287.057(1)(c). At least 90 days before issuing an invitation to negotiate, the agency shall compile and publish a databook consisting of a comprehensive set of utilization and spending data consistent with actuarial rate-setting practices and standards. The source of the data in the databook must include, at a minimum, the 24 most recent months of validated data from the Medicaid Encounter Data System, and the databook must delineate utilization use by age, gender, eligibility group, geographic area, and aggregate clinical risk score. The statewide managed care program includes the following regions:(a) Region A, which consists of Bay, Calhoun, Escambia, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton, and Washington Counties.
(b) Region B, which consists of Alachua, Baker, Bradford, Citrus, Clay, Columbia, Dixie, Duval, Flagler, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Nassau, Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia Counties.
(c) Region C, which consists of Pasco and Pinellas Counties.
(d) Region D, which consists of Hardee, Highlands, Hillsborough, Manatee, and Polk Counties.
(e) Region E, which consists of Brevard, Orange, Osceola, and Seminole Counties.
(f) Region F, which consists of Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota Counties.
(g) Region G, which consists of Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie Counties.
(h) Region H, which consists of Broward County.
(i) Region I, which consists of Miami-Dade and Monroe Counties.
2. Have well-defined programs for recognizing patient-centered medical homes and providing for increased compensation for recognized medical homes, as defined by the plan.
3. Are organizations that are based in and perform operational functions in this state, in-house or through contractual arrangements, by staff located in this state. Using a tiered approach, the highest number of points shall be awarded to a plan that has all or substantially all of its operational functions performed in the state. The second highest number of points shall be awarded to a plan that has a majority of its operational functions performed in the state. The agency may establish a third tier; however, preference points may not be awarded to plans that perform only community outreach, medical director functions, and state administrative functions in the state. For purposes of this subparagraph, operational functions include corporate headquarters, claims processing, member services, provider relations, utilization and prior authorization, case management, disease and quality functions, and finance and administration. For purposes of this subparagraph, the term “corporate headquarters” means the principal office of the organization, which may not be a subsidiary, directly or indirectly through one or more subsidiaries of, or a joint venture with, any other entity whose principal office is not located in the state.
4. Have contracts or other arrangements for cancer disease management programs that have a proven record of clinical efficiencies and cost savings.
5. Have contracts or other arrangements for diabetes disease management programs that have a proven record of clinical efficiencies and cost savings.
6. Have a claims payment process that ensures that claims that are not contested or denied will be promptly paid pursuant to s. 641.3155.