Florida Senate - 2009 SB 2464
By Senator Sobel
31-00548A-09 20092464__
1 A bill to be entitled
2 An act relating to the Medicaid managed care pilot
3 program; repealing s. 409.91211, F.S., relating to the
4 Medicaid managed care pilot program; amending s.
5 409.912, F.S.; deleting references to the pilot
6 program to conform to changes made by the act;
7 providing an effective date.
8
9 Be It Enacted by the Legislature of the State of Florida:
10
11 Section 1. Section 409.91211, Florida Statutes, is
12 repealed.
13 Section 2. Paragraphs (b) and (d) of subsection (4) and
14 subsection (34) of section 409.912, Florida Statutes, are
15 amended to read:
16 409.912 Cost-effective purchasing of health care.—The
17 agency shall purchase goods and services for Medicaid recipients
18 in the most cost-effective manner consistent with the delivery
19 of quality medical care. To ensure that medical services are
20 effectively utilized, the agency may, in any case, require a
21 confirmation or second physician’s opinion of the correct
22 diagnosis for purposes of authorizing future services under the
23 Medicaid program. This section does not restrict access to
24 emergency services or poststabilization care services as defined
25 in 42 C.F.R. part 438.114. Such confirmation or second opinion
26 shall be rendered in a manner approved by the agency. The agency
27 shall maximize the use of prepaid per capita and prepaid
28 aggregate fixed-sum basis services when appropriate and other
29 alternative service delivery and reimbursement methodologies,
30 including competitive bidding pursuant to s. 287.057, designed
31 to facilitate the cost-effective purchase of a case-managed
32 continuum of care. The agency shall also require providers to
33 minimize the exposure of recipients to the need for acute
34 inpatient, custodial, and other institutional care and the
35 inappropriate or unnecessary use of high-cost services. The
36 agency shall contract with a vendor to monitor and evaluate the
37 clinical practice patterns of providers in order to identify
38 trends that are outside the normal practice patterns of a
39 provider’s professional peers or the national guidelines of a
40 provider’s professional association. The vendor must be able to
41 provide information and counseling to a provider whose practice
42 patterns are outside the norms, in consultation with the agency,
43 to improve patient care and reduce inappropriate utilization.
44 The agency may mandate prior authorization, drug therapy
45 management, or disease management participation for certain
46 populations of Medicaid beneficiaries, certain drug classes, or
47 particular drugs to prevent fraud, abuse, overuse, and possible
48 dangerous drug interactions. The Pharmaceutical and Therapeutics
49 Committee shall make recommendations to the agency on drugs for
50 which prior authorization is required. The agency shall inform
51 the Pharmaceutical and Therapeutics Committee of its decisions
52 regarding drugs subject to prior authorization. The agency is
53 authorized to limit the entities it contracts with or enrolls as
54 Medicaid providers by developing a provider network through
55 provider credentialing. The agency may competitively bid single
56 source-provider contracts if procurement of goods or services
57 results in demonstrated cost savings to the state without
58 limiting access to care. The agency may limit its network based
59 on the assessment of beneficiary access to care, provider
60 availability, provider quality standards, time and distance
61 standards for access to care, the cultural competence of the
62 provider network, demographic characteristics of Medicaid
63 beneficiaries, practice and provider-to-beneficiary standards,
64 appointment wait times, beneficiary use of services, provider
65 turnover, provider profiling, provider licensure history,
66 previous program integrity investigations and findings, peer
67 review, provider Medicaid policy and billing compliance records,
68 clinical and medical record audits, and other factors. Providers
69 shall not be entitled to enrollment in the Medicaid provider
70 network. The agency shall determine instances in which allowing
71 Medicaid beneficiaries to purchase durable medical equipment and
72 other goods is less expensive to the Medicaid program than long
73 term rental of the equipment or goods. The agency may establish
74 rules to facilitate purchases in lieu of long-term rentals in
75 order to protect against fraud and abuse in the Medicaid program
76 as defined in s. 409.913. The agency may seek federal waivers
77 necessary to administer these policies.
78 (4) The agency may contract with:
79 (b) An entity that is providing comprehensive behavioral
80 health care services to certain Medicaid recipients through a
81 capitated, prepaid arrangement pursuant to the federal waiver
82 provided for by s. 409.905(5). Such an entity must be licensed
83 under chapter 624, chapter 636, or chapter 641 and must possess
84 the clinical systems and operational competence to manage risk
85 and provide comprehensive behavioral health care to Medicaid
86 recipients. As used in this paragraph, the term “comprehensive
87 behavioral health care services” means covered mental health and
88 substance abuse treatment services that are available to
89 Medicaid recipients. The secretary of the Department of Children
90 and Family Services shall approve provisions of procurements
91 related to children in the department’s care or custody prior to
92 enrolling such children in a prepaid behavioral health plan. Any
93 contract awarded under this paragraph must be competitively
94 procured. In developing the behavioral health care prepaid plan
95 procurement document, the agency shall ensure that the
96 procurement document requires the contractor to develop and
97 implement a plan to ensure compliance with s. 394.4574 related
98 to services provided to residents of licensed assisted living
99 facilities that hold a limited mental health license. Except as
100 provided in subparagraph 8., and except in counties where the
101 Medicaid managed care pilot program is authorized pursuant to s.
102 409.91211, the agency shall seek federal approval to contract
103 with a single entity meeting these requirements to provide
104 comprehensive behavioral health care services to all Medicaid
105 recipients not enrolled in a Medicaid managed care plan
106 authorized under s. 409.91211 or a Medicaid health maintenance
107 organization in an AHCA area. In an AHCA area where the Medicaid
108 managed care pilot program is authorized pursuant to s.
109 409.91211 in one or more counties, the agency may procure a
110 contract with a single entity to serve the remaining counties as
111 an AHCA area or the remaining counties may be included with an
112 adjacent AHCA area and shall be subject to this paragraph. Each
113 entity must offer sufficient choice of providers in its network
114 to ensure recipient access to care and the opportunity to select
115 a provider with whom they are satisfied. The network shall
116 include all public mental health hospitals. To ensure unimpaired
117 access to behavioral health care services by Medicaid
118 recipients, all contracts issued pursuant to this paragraph
119 shall require 80 percent of the capitation paid to the managed
120 care plan, including health maintenance organizations, to be
121 expended for the provision of behavioral health care services.
122 In the event the managed care plan expends less than 80 percent
123 of the capitation paid pursuant to this paragraph for the
124 provision of behavioral health care services, the difference
125 shall be returned to the agency. The agency shall provide the
126 managed care plan with a certification letter indicating the
127 amount of capitation paid during each calendar year for the
128 provision of behavioral health care services pursuant to this
129 section. The agency may reimburse for substance abuse treatment
130 services on a fee-for-service basis until the agency finds that
131 adequate funds are available for capitated, prepaid
132 arrangements.
133 1. By January 1, 2001, the agency shall modify the
134 contracts with the entities providing comprehensive inpatient
135 and outpatient mental health care services to Medicaid
136 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
137 Counties, to include substance abuse treatment services.
138 2. By July 1, 2003, the agency and the Department of
139 Children and Family Services shall execute a written agreement
140 that requires collaboration and joint development of all policy,
141 budgets, procurement documents, contracts, and monitoring plans
142 that have an impact on the state and Medicaid community mental
143 health and targeted case management programs.
144 3. Except as provided in subparagraph 8., by July 1, 2006,
145 the agency and the Department of Children and Family Services
146 shall contract with managed care entities in each AHCA area
147 except area 6 or arrange to provide comprehensive inpatient and
148 outpatient mental health and substance abuse services through
149 capitated prepaid arrangements to all Medicaid recipients who
150 are eligible to participate in such plans under federal law and
151 regulation. In AHCA areas where eligible individuals number less
152 than 150,000, the agency shall contract with a single managed
153 care plan to provide comprehensive behavioral health services to
154 all recipients who are not enrolled in a Medicaid health
155 maintenance organization or a Medicaid capitated managed care
156 plan authorized under s. 409.91211. The agency may contract with
157 more than one comprehensive behavioral health provider to
158 provide care to recipients who are not enrolled in a Medicaid
159 capitated managed care plan authorized under s. 409.91211 or a
160 Medicaid health maintenance organization in AHCA areas where the
161 eligible population exceeds 150,000. In an AHCA area where the
162 Medicaid managed care pilot program is authorized pursuant to s.
163 409.91211 in one or more counties, the agency may procure a
164 contract with a single entity to serve the remaining counties as
165 an AHCA area or the remaining counties may be included with an
166 adjacent AHCA area and shall be subject to this paragraph.
167 Contracts for comprehensive behavioral health providers awarded
168 pursuant to this section shall be competitively procured. Both
169 for-profit and not-for-profit corporations shall be eligible to
170 compete. Managed care plans contracting with the agency under
171 subsection (3) shall provide and receive payment for the same
172 comprehensive behavioral health benefits as provided in AHCA
173 rules, including handbooks incorporated by reference. In AHCA
174 area 11, the agency shall contract with at least two
175 comprehensive behavioral health care providers to provide
176 behavioral health care to recipients in that area who are
177 enrolled in, or assigned to, the MediPass program. One of the
178 behavioral health care contracts shall be with the existing
179 provider service network pilot project, as described in
180 paragraph (d), for the purpose of demonstrating the cost
181 effectiveness of the provision of quality mental health services
182 through a public hospital-operated managed care model. Payment
183 shall be at an agreed-upon capitated rate to ensure cost
184 savings. Of the recipients in area 11 who are assigned to
185 MediPass under the provisions of s. 409.9122(2)(k), a minimum of
186 50,000 of those MediPass-enrolled recipients shall be assigned
187 to the existing provider service network in area 11 for their
188 behavioral care.
189 4. By October 1, 2003, the agency and the department shall
190 submit a plan to the Governor, the President of the Senate, and
191 the Speaker of the House of Representatives which provides for
192 the full implementation of capitated prepaid behavioral health
193 care in all areas of the state.
194 a. Implementation shall begin in 2003 in those AHCA areas
195 of the state where the agency is able to establish sufficient
196 capitation rates.
197 b. If the agency determines that the proposed capitation
198 rate in any area is insufficient to provide appropriate
199 services, the agency may adjust the capitation rate to ensure
200 that care will be available. The agency and the department may
201 use existing general revenue to address any additional required
202 match but may not over-obligate existing funds on an annualized
203 basis.
204 c. Subject to any limitations provided for in the General
205 Appropriations Act, the agency, in compliance with appropriate
206 federal authorization, shall develop policies and procedures
207 that allow for certification of local and state funds.
208 5. Children residing in a statewide inpatient psychiatric
209 program, or in a Department of Juvenile Justice or a Department
210 of Children and Family Services residential program approved as
211 a Medicaid behavioral health overlay services provider shall not
212 be included in a behavioral health care prepaid health plan or
213 any other Medicaid managed care plan pursuant to this paragraph.
214 6. In converting to a prepaid system of delivery, the
215 agency shall in its procurement document require an entity
216 providing only comprehensive behavioral health care services to
217 prevent the displacement of indigent care patients by enrollees
218 in the Medicaid prepaid health plan providing behavioral health
219 care services from facilities receiving state funding to provide
220 indigent behavioral health care, to facilities licensed under
221 chapter 395 which do not receive state funding for indigent
222 behavioral health care, or reimburse the unsubsidized facility
223 for the cost of behavioral health care provided to the displaced
224 indigent care patient.
225 7. Traditional community mental health providers under
226 contract with the Department of Children and Family Services
227 pursuant to part IV of chapter 394, child welfare providers
228 under contract with the Department of Children and Family
229 Services in areas 1 and 6, and inpatient mental health providers
230 licensed pursuant to chapter 395 must be offered an opportunity
231 to accept or decline a contract to participate in any provider
232 network for prepaid behavioral health services.
233 8. All Medicaid-eligible children, except children in area
234 1 and children in Highlands County, Hardee County, Polk County,
235 or Manatee County of area 6, who are open for child welfare
236 services in the HomeSafeNet system, shall receive their
237 behavioral health care services through a specialty prepaid plan
238 operated by community-based lead agencies either through a
239 single agency or formal agreements among several agencies. The
240 specialty prepaid plan must result in savings to the state
241 comparable to savings achieved in other Medicaid managed care
242 and prepaid programs. Such plan must provide mechanisms to
243 maximize state and local revenues. The specialty prepaid plan
244 shall be developed by the agency and the Department of Children
245 and Family Services. The agency is authorized to seek any
246 federal waivers to implement this initiative. Medicaid-eligible
247 children whose cases are open for child welfare services in the
248 HomeSafeNet system and who reside in AHCA area 10 are exempt
249 from the specialty prepaid plan upon the development of a
250 service delivery mechanism for children who reside in area 10 as
251 specified in s. 409.91211(3)(dd).
252 (d) A provider service network may be reimbursed on a fee
253 for-service or prepaid basis. A provider service network which
254 is reimbursed by the agency on a prepaid basis shall be exempt
255 from parts I and III of chapter 641, but must comply with the
256 solvency requirements in s. 641.2261(2) and meet appropriate
257 financial reserve, quality assurance, and patient rights
258 requirements as established by the agency. Medicaid recipients
259 assigned to a provider service network shall be chosen equally
260 from those who would otherwise have been assigned to prepaid
261 plans and MediPass. The agency is authorized to seek federal
262 Medicaid waivers as necessary to implement the provisions of
263 this section. Any contract previously awarded to a provider
264 service network operated by a hospital pursuant to this
265 subsection shall remain in effect for a period of 3 years
266 following the current contract expiration date, regardless of
267 any contractual provisions to the contrary. A provider service
268 network is a network established or organized and operated by a
269 health care provider, or group of affiliated health care
270 providers, including minority physician networks and emergency
271 room diversion programs that meet the requirements of s.
272 409.91211, which provides a substantial proportion of the health
273 care items and services under a contract directly through the
274 provider or affiliated group of providers and may make
275 arrangements with physicians or other health care professionals,
276 health care institutions, or any combination of such individuals
277 or institutions to assume all or part of the financial risk on a
278 prospective basis for the provision of basic health services by
279 the physicians, by other health professionals, or through the
280 institutions. The health care providers must have a controlling
281 interest in the governing body of the provider service network
282 organization.
283 (34) The agency and entities that contract with the agency
284 to provide health care services to Medicaid recipients under
285 this section or s. ss. 409.91211 and 409.9122 must comply with
286 the provisions of s. 641.513 in providing emergency services and
287 care to Medicaid recipients and MediPass recipients. Where
288 feasible, safe, and cost-effective, the agency shall encourage
289 hospitals, emergency medical services providers, and other
290 public and private health care providers to work together in
291 their local communities to enter into agreements or arrangements
292 to ensure access to alternatives to emergency services and care
293 for those Medicaid recipients who need nonemergent care. The
294 agency shall coordinate with hospitals, emergency medical
295 services providers, private health plans, capitated managed care
296 networks as established in s. 409.91211, and other public and
297 private health care providers to implement the provisions of ss.
298 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to develop
299 and implement emergency department diversion programs for
300 Medicaid recipients.
301 Section 3. This act shall take effect July 1, 2009.