Florida Senate - 2009 SENATOR AMENDMENT
Bill No. CS for CS for CS for SB 1986
Barcode 884730
LEGISLATIVE ACTION
Senate . House
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Floor: 3/AD/2R .
04/23/2009 05:22 PM .
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Senator Peaden moved the following:
1 Senate Substitute for Amendment (333902) (with directory
2 and title amendments)
3
4 Delete lines 780 - 830
5 and insert:
6 (4) The agency may contract with:
7 (b) An entity that is providing comprehensive behavioral
8 health care services to certain Medicaid recipients through a
9 capitated, prepaid arrangement pursuant to the federal waiver
10 provided for by s. 409.905(5). Such an entity must be licensed
11 under chapter 624, chapter 636, or chapter 641, or authorized
12 under paragraph (c), and must possess the clinical systems and
13 operational competence to manage risk and provide comprehensive
14 behavioral health care to Medicaid recipients. As used in this
15 paragraph, the term “comprehensive behavioral health care
16 services” means covered mental health and substance abuse
17 treatment services that are available to Medicaid recipients.
18 The secretary of the Department of Children and Family Services
19 shall approve provisions of procurements related to children in
20 the department’s care or custody before prior to enrolling such
21 children in a prepaid behavioral health plan. Any contract
22 awarded under this paragraph must be competitively procured. In
23 developing the behavioral health care prepaid plan procurement
24 document, the agency shall ensure that the procurement document
25 requires the contractor to develop and implement a plan to
26 ensure compliance with s. 394.4574 related to services provided
27 to residents of licensed assisted living facilities that hold a
28 limited mental health license. Except as provided in
29 subparagraph 8., and except in counties where the Medicaid
30 managed care pilot program is authorized pursuant to s.
31 409.91211, the agency shall seek federal approval to contract
32 with a single entity meeting these requirements to provide
33 comprehensive behavioral health care services to all Medicaid
34 recipients not enrolled in a Medicaid managed care plan
35 authorized under s. 409.91211 or a Medicaid health maintenance
36 organization in an AHCA area. In an AHCA area where the Medicaid
37 managed care pilot program is authorized pursuant to s.
38 409.91211 in one or more counties, the agency may procure a
39 contract with a single entity to serve the remaining counties as
40 an AHCA area or the remaining counties may be included with an
41 adjacent AHCA area and are shall be subject to this paragraph.
42 Each entity must offer a sufficient choice of providers in its
43 network to ensure recipient access to care and the opportunity
44 to select a provider with whom they are satisfied. The network
45 shall include all public mental health hospitals. To ensure
46 unimpaired access to behavioral health care services by Medicaid
47 recipients, all contracts issued pursuant to this paragraph must
48 shall require 80 percent of the capitation paid to the managed
49 care plan, including health maintenance organizations, to be
50 expended for the provision of behavioral health care services.
51 If In the event the managed care plan expends less than 80
52 percent of the capitation paid pursuant to this paragraph for
53 the provision of behavioral health care services, the difference
54 shall be returned to the agency. The agency shall provide the
55 managed care plan with a certification letter indicating the
56 amount of capitation paid during each calendar year for the
57 provision of behavioral health care services pursuant to this
58 section. The agency may reimburse for substance abuse treatment
59 services on a fee-for-service basis until the agency finds that
60 adequate funds are available for capitated, prepaid
61 arrangements.
62 1. By January 1, 2001, the agency shall modify the
63 contracts with the entities providing comprehensive inpatient
64 and outpatient mental health care services to Medicaid
65 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
66 Counties, to include substance abuse treatment services.
67 2. By July 1, 2003, the agency and the Department of
68 Children and Family Services shall execute a written agreement
69 that requires collaboration and joint development of all policy,
70 budgets, procurement documents, contracts, and monitoring plans
71 that have an impact on the state and Medicaid community mental
72 health and targeted case management programs.
73 3. Except as provided in subparagraph 8., by July 1, 2006,
74 the agency and the Department of Children and Family Services
75 shall contract with managed care entities in each AHCA area
76 except area 6 or arrange to provide comprehensive inpatient and
77 outpatient mental health and substance abuse services through
78 capitated prepaid arrangements to all Medicaid recipients who
79 are eligible to participate in such plans under federal law and
80 regulation. In AHCA areas where eligible individuals number less
81 than 150,000, the agency shall contract with a single managed
82 care plan to provide comprehensive behavioral health services to
83 all recipients who are not enrolled in a Medicaid health
84 maintenance organization or a Medicaid capitated managed care
85 plan authorized under s. 409.91211. The agency may contract with
86 more than one comprehensive behavioral health provider to
87 provide care to recipients who are not enrolled in a Medicaid
88 capitated managed care plan authorized under s. 409.91211 or a
89 Medicaid health maintenance organization in AHCA areas where the
90 eligible population exceeds 150,000. In an AHCA area where the
91 Medicaid managed care pilot program is authorized pursuant to s.
92 409.91211 in one or more counties, the agency may procure a
93 contract with a single entity to serve the remaining counties as
94 an AHCA area or the remaining counties may be included with an
95 adjacent AHCA area and shall be subject to this paragraph.
96 Contracts for comprehensive behavioral health providers awarded
97 pursuant to this section shall be competitively procured. Both
98 for-profit and not-for-profit corporations are shall be eligible
99 to compete. Managed care plans contracting with the agency under
100 subsection (3) shall provide and receive payment for the same
101 comprehensive behavioral health benefits as provided in AHCA
102 rules, including handbooks incorporated by reference. In AHCA
103 area 11, the agency shall contract with at least two
104 comprehensive behavioral health care providers to provide
105 behavioral health care to recipients in that area who are
106 enrolled in, or assigned to, the MediPass program. One of the
107 behavioral health care contracts must shall be with the existing
108 provider service network pilot project, as described in
109 paragraph (d), for the purpose of demonstrating the cost
110 effectiveness of the provision of quality mental health services
111 through a public hospital-operated managed care model. Payment
112 shall be at an agreed-upon capitated rate to ensure cost
113 savings. Of the recipients in area 11 who are assigned to
114 MediPass under the provisions of s. 409.9122(2)(k), a minimum of
115 50,000 of those MediPass-enrolled recipients shall be assigned
116 to the existing provider service network in area 11 for their
117 behavioral care.
118 4. By October 1, 2003, the agency and the department shall
119 submit a plan to the Governor, the President of the Senate, and
120 the Speaker of the House of Representatives which provides for
121 the full implementation of capitated prepaid behavioral health
122 care in all areas of the state.
123 a. Implementation shall begin in 2003 in those AHCA areas
124 of the state where the agency is able to establish sufficient
125 capitation rates.
126 b. If the agency determines that the proposed capitation
127 rate in any area is insufficient to provide appropriate
128 services, the agency may adjust the capitation rate to ensure
129 that care will be available. The agency and the department may
130 use existing general revenue to address any additional required
131 match but may not over-obligate existing funds on an annualized
132 basis.
133 c. Subject to any limitations provided for in the General
134 Appropriations Act, the agency, in compliance with appropriate
135 federal authorization, shall develop policies and procedures
136 that allow for certification of local and state funds.
137 5. Children residing in a statewide inpatient psychiatric
138 program, or in a Department of Juvenile Justice or a Department
139 of Children and Family Services residential program approved as
140 a Medicaid behavioral health overlay services provider may shall
141 not be included in a behavioral health care prepaid health plan
142 or any other Medicaid managed care plan pursuant to this
143 paragraph.
144 6. In converting to a prepaid system of delivery, the
145 agency shall in its procurement document require an entity
146 providing only comprehensive behavioral health care services to
147 prevent the displacement of indigent care patients by enrollees
148 in the Medicaid prepaid health plan providing behavioral health
149 care services from facilities receiving state funding to provide
150 indigent behavioral health care, to facilities licensed under
151 chapter 395 which do not receive state funding for indigent
152 behavioral health care, or reimburse the unsubsidized facility
153 for the cost of behavioral health care provided to the displaced
154 indigent care patient.
155 7. Traditional community mental health providers under
156 contract with the Department of Children and Family Services
157 pursuant to part IV of chapter 394, child welfare providers
158 under contract with the Department of Children and Family
159 Services in areas 1 and 6, and inpatient mental health providers
160 licensed pursuant to chapter 395 must be offered an opportunity
161 to accept or decline a contract to participate in any provider
162 network for prepaid behavioral health services.
163 8. All Medicaid-eligible children, except children in area
164 1 and children in Highlands County, Hardee County, Polk County,
165 or Manatee County of area 6, that who are open for child welfare
166 services in the HomeSafeNet system, shall receive their
167 behavioral health care services through a specialty prepaid plan
168 operated by community-based lead agencies either through a
169 single agency or formal agreements among several agencies. The
170 specialty prepaid plan must result in savings to the state
171 comparable to savings achieved in other Medicaid managed care
172 and prepaid programs. Such plan must provide mechanisms to
173 maximize state and local revenues. The specialty prepaid plan
174 shall be developed by the agency and the Department of Children
175 and Family Services. The agency may is authorized to seek any
176 federal waivers to implement this initiative. Medicaid-eligible
177 children whose cases are open for child welfare services in the
178 HomeSafeNet system and who reside in AHCA area 10 are exempt
179 from the specialty prepaid plan upon the development of a
180 service delivery mechanism for children who reside in area 10 as
181 specified in s. 409.91211(3)(dd).
182 (14)(a) The agency shall operate or contract for the
183 operation of utilization management and incentive systems
184 designed to encourage cost-effective use of services and to
185 eliminate services that are medically unnecessary. The agency
186 shall track Medicaid provider prescription and billing patterns
187 and evaluate them against Medicaid medical necessity criteria
188 and coverage and limitation guidelines adopted by rule. Medical
189 necessity determination requires that service be consistent with
190 symptoms or confirmed diagnosis of illness or injury under
191 treatment and not in excess of the patient’s needs. The agency
192 shall conduct reviews of provider exceptions to peer group norms
193 and shall, using statistical methodologies, provider profiling,
194 and analysis of billing patterns, detect and investigate
195 abnormal or unusual increases in billing or payment of claims
196 for Medicaid services and medically unnecessary provision of
197 services. Providers that demonstrate a pattern of submitting
198 claims for medically unnecessary services shall be referred to
199 the Medicaid program integrity unit for investigation. In its
200 annual report, required in s. 409.913, the agency shall report
201 on its efforts to control overutilization as described in this
202 paragraph.
203 (b) The agency shall develop a procedure for determining
204 whether health care providers and service vendors can provide
205 the Medicaid program using a business case that demonstrates
206 whether a particular good or service can offset the cost of
207 providing the good or service in an alternative setting or
208 through other means and therefore should receive a higher
209 reimbursement. The business case must include, but need not be
210 limited to:
211 1. A detailed description of the good or service to be
212 provided, a description and analysis of the agency’s current
213 performance of the service, and a rationale documenting how
214 providing the service in an alternative setting would be in the
215 best interest of the state, the agency, and its clients.
216 2. A cost-benefit analysis documenting the estimated
217 specific direct and indirect costs, savings, performance
218 improvements, risks, and qualitative and quantitative benefits
219 involved in or resulting from providing the service. The cost
220 benefit analysis must include a detailed plan and timeline
221 identifying all actions that must be implemented to realize
222 expected benefits. The Secretary of Health Care Administration
223 shall verify that all costs, savings, and benefits are valid and
224 achievable.
225 (c) If the agency determines that the increased
226 reimbursement is cost-effective, the agency shall recommend a
227 change in the reimbursement schedule for that particular good or
228 service. If, within 12 months after implementing any rate change
229 under this procedure, the agency determines that costs were not
230 offset by the increased reimbursement schedule, the agency may
231 revert to the former reimbursement schedule for the particular
232 good or service.
233 (17) An entity contracting on a prepaid or fixed-sum basis
234 shall meet the, in addition to meeting any applicable statutory
235 surplus requirements of s. 641.225, also maintain at all times
236 in the form of cash, investments that mature in less than 180
237 days allowable as admitted assets by the Office of Insurance
238 Regulation, and restricted funds or deposits controlled by the
239 agency or the Office of Insurance Regulation, a surplus amount
240 equal to one-and-one-half times the entity’s monthly Medicaid
241 prepaid revenues. As used in this subsection, the term “surplus”
242 means the entity’s total assets minus total liabilities. If an
243 entity’s surplus falls below an amount equal to the surplus
244 requirements of s. 641.225 one-and-one-half times the entity’s
245 monthly Medicaid prepaid revenues, the agency shall prohibit the
246 entity from engaging in marketing and preenrollment activities,
247 shall cease to process new enrollments, and may shall not renew
248 the entity’s contract until the required balance is achieved.
249 The requirements of this subsection do not apply:
250 (a) Where a public entity agrees to fund any deficit
251 incurred by the contracting entity; or
252 (b) Where the entity’s performance and obligations are
253 guaranteed in writing by a guaranteeing organization which:
254 1. Has been in operation for at least 5 years and has
255 assets in excess of $50 million; or
256 2. Submits a written guarantee acceptable to the agency
257 which is irrevocable during the term of the contracting entity’s
258 contract with the agency and, upon termination of the contract,
259 until the agency receives proof of satisfaction of all
260 outstanding obligations incurred under the contract.
261
262 ====== D I R E C T O R Y C L A U S E A M E N D M E N T ======
263 And the directory clause is amended as follows:
264 Delete lines 716 - 717
265 and insert:
266 Section 12. Paragraph (b) of subsection (4), subsection
267 (14), and subsection (17) of section 409.912, Florida Statutes,
268 are amended to read:
269
270 ================= T I T L E A M E N D M E N T ================
271 And the title is amended as follows:
272 Delete lines 49 - 53
273 and insert:
274 providers; amending s. 409.912, F.S.; requiring that
275 certain entities that provide comprehensive behavioral
276 health care services to certain Medicaid recipients be
277 licensed or authorized; requiring the Agency for
278 Health Care Administration to establish norms for the
279 utilization of Medicaid services; requiring the agency
280 to submit a report relating to the overutilization of
281 Medicaid services; revising the requirement for an
282 entity that contracts on a prepaid or fixed-sum basis
283 to meet certain surplus requirements; deleting the
284 requirement that an entity maintain certain
285 investments and restricted funds or deposits; revising
286 the circumstances in which the agency must prohibit
287 the entity from engaging in certain activities, cease
288 to process new enrollments, and not renew the entity’s
289 contract; amending s.