HB 7191

1	A bill to be entitled
2	An act relating to self-directed care and mental health
3	system improvements; amending s. 394.9084, F.S., relating
4	to the Florida Self-Directed Care program; requiring the
5	Department of Children and Family Services to expand
6	access to the program, within existing resources; deleting
7	provisions relating to development of a pilot project;
8	revising provisions relating to implementation and
9	administration of the program; providing for program
10	applicants to be considered for enrollment regardless of
11	level of functioning; providing for sources of funding;
12	removing vocational rehabilitation and the Social Security
13	Administration as subcomponents of the program; requiring
14	eligible individuals to agree with program requirements
15	and responsibilities; defining the term "independent
16	financial agent"; requiring the independent financial
17	agent, rather than the managing entity, to pay for certain
18	services; removing obsolete provisions relating to
19	obtaining federal waivers; providing for family-directed
20	care; requiring an annual evaluation of the program;
21	removing a provision authorizing the department to provide
22	certain funding for the evaluation; deleting the
23	expiration date of the program; amending s. 409.912, F.S.;
24	authorizing the Agency for Health Care Administration to
25	contract with provider service networks specializing in
26	psychiatric disabilities to provide Medicaid services;
27	providing for assignment to psychiatric specialty provider
28	service networks; amending s. 409.91211, F.S.; authorizing
29	the agency to seek and contract with provider service
30	networks specializing in psychiatric disabilities to
31	provide services in the Medicaid managed care pilot
32	program; providing for plan assignment processes;
33	authorizing the agency to consider diagnoses and
34	disabilities in making plan assignments; providing an
35	effective date.
36
37	Be It Enacted by the Legislature of the State of Florida:
38
39	Section 1.  Section 394.9084, Florida Statutes, is amended
40	to read:
41	394.9084  Florida Self-Directed Care program.--
42	(1)  The Department of Children and Family Services, in
43	cooperation with the Agency for Health Care Administration,
44	shall make the Florida Self-Directed Care program model of
45	service delivery available in every district of the department
46	using existing resources. The Florida Self-Directed Care program
47	is a participant-directed may develop a client-directed and
48	choice-based program that provides pilot project in district 4
49	and three other districts to provide mental health treatment and
50	support services for to adults with severe and persistent who
51	have a serious mental illness. The department may also develop
52	and implement a client-directed and choice-based pilot project
53	in one district to provide mental health treatment and support
54	services for children with a serious emotional disturbance who
55	live at home. If established, any staff who work with children
56	must be screened under s. 435.04. The department projects shall
57	implement a payment mechanism model in which each participant
58	client controls the money that is available for that
59	participant's client's mental health treatment and support
60	services. The department shall establish interagency cooperative
61	agreements and work with the agency as necessary, the division,
62	and the Social Security Administration to implement and
63	administer the Florida Self-Directed Care program.
64	(2)  To be eligible for enrollment in the Florida Self-
65	Directed Care program, a person must be an adult with a severe
66	and persistent mental illness. Florida Self-Directed Care
67	program applicants with different levels of psychological,
68	social, and occupational functioning may be considered for
69	enrollment. Individuals eligible for enrollment must agree to
70	Florida Self-Directed Care program requirements and
71	responsibilities.
72	(3)  The Florida Self-Directed Care program includes the
73	following sources of funding has four subcomponents:
74	(a)  State-funded Department mental health services, which
75	include community mental health outpatient, community support,
76	and case management services funded through the department. This
77	subcomponent excludes Florida Assertive Community Treatment
78	(FACT) services for adults; residential services; and emergency
79	stabilization services, including crisis stabilization units,
80	short-term residential treatment, and inpatient services.
81	(b)  State-funded and federally funded Agency mental health
82	services, which include community mental health services and
83	mental health targeted case management services reimbursed by
84	Medicaid.
85	(c)  Vocational rehabilitation, which includes funds
86	available for an eligible participant as provided by the
87	Rehabilitation Act of 1973, 29 U.S.C. chapter 16, as amended.
88	(d)  Social Security Administration.
89	(4)  The independent financial agent managing entity shall
90	pay for the cost-efficient community-based services the
91	participant selects to meet his or her mental health care and
92	vocational rehabilitation needs and goals as identified on his
93	or her recovery plan. For purposes of this section, the term
94	"independent financial agent" means a third-party administrator
95	who is an individual, an entity, or a program that does not
96	provide mental health services. The fees authorized to be paid
97	to the independent financial agent shall be paid from existing
98	program funds.
99	(5)(a)  The department and the agency shall take all
100	necessary action to ensure state compliance with federal
101	regulations. The agency, in collaboration with the department,
102	shall seek federal Medicaid waivers, and the department shall
103	expeditiously seek any available Supplemental Security
104	Administration waivers under s. 1110(b) of the federal Social
105	Security Act; and the division, in collaboration with the
106	department, shall seek federal approval to participate in the
107	Florida Self-Directed Care program. No later than June 30, 2005,
108	the department, agency, and division shall amend and update
109	their strategic and state plans to reflect participation in the
110	projects, including intent to seek federal approval to provide
111	cashout options for eligible services for participants in the
112	projects.
113	(b)  The department may apply for and use any funds from
114	private, state, and federal grants provided for self-directed
115	care, family-directed care, voucher, and self-determination
116	programs, including those providing substance abuse and mental
117	health care.
118	(6)  The department, the agency, and the division may
119	transfer funds to the independent financial agent managing
120	entity.
121	(7)  The department and, the agency, and the division shall
122	have rulemaking authority pursuant to ss. 120.536(1) and 120.54
123	to implement the provisions of this section. These rules shall
124	be for the purpose of enhancing choice in and control over the
125	purchased mental health and vocational rehabilitative services
126	accessed by Florida Self-Directed Care program participants.
127	(8)  The department and the agency shall will complete a
128	memorandum of agreement to delineate management roles for
129	operation of the Florida Self-Directed Care program.
130	(9)  The department and, the agency, and the division shall
131	each, on an ongoing basis, review and assess the implementation
132	of the Florida Self-Directed Care program.
133	(a)  The department shall will implement an annual
134	evaluation of the program and shall will include recommendations
135	for improvements in the program.
136	(b)  At a minimum, the evaluation must compare between
137	program participants and nonparticipants:
138	1.  Re-hospitalization rates.
139	2.  Levels of satisfaction.
140	3.  Service utilization rates.
141	4.  Residential stability.
142	5.  Levels of community integration and interaction.
143	(c)  The evaluation must assess evaluate adherence to the
144	Centers for Medicare and Medicaid self-direction requirements,
145	including:
146	1.  Person-centered planning.
147	2.  Individual budgets.
148	3.  Availability of independently brokered services from
149	recovery coaches and quality advocates.
150	4.  Access to the program by all who are eligible to
151	enroll.
152	5.  Participant safety and program incident management
153	planning.
154	6.  An independently mediated grievance process.
155	(d)  The evaluation must assess the economic self-
156	sufficiency of the program participants, including the number of
157	Individual Development Accounts.
158	(e)  The evaluation must assess any adverse incidents
159	resulting from the Florida Self-Directed Care program, including
160	participant consumer grievances, conflicts of interest, and
161	patterns of self-referral by licensed professions.
162
163	The department is authorized to spend up to $100,000 to pay for
164	the evaluation. If the agency and the department obtain a
165	federal waiver, the evaluation will be used to determine
166	effectiveness.
167	(10)  This section expires July 1, 2008.
168	Section 2.  Paragraph (d) of subsection (4) of section
169	409.912, Florida Statutes, is amended to read:
170	409.912  Cost-effective purchasing of health care.--The
171	agency shall purchase goods and services for Medicaid recipients
172	in the most cost-effective manner consistent with the delivery
173	of quality medical care. To ensure that medical services are
174	effectively utilized, the agency may, in any case, require a
175	confirmation or second physician's opinion of the correct
176	diagnosis for purposes of authorizing future services under the
177	Medicaid program. This section does not restrict access to
178	emergency services or poststabilization care services as defined
179	in 42 C.F.R. part 438.114. Such confirmation or second opinion
180	shall be rendered in a manner approved by the agency. The agency
181	shall maximize the use of prepaid per capita and prepaid
182	aggregate fixed-sum basis services when appropriate and other
183	alternative service delivery and reimbursement methodologies,
184	including competitive bidding pursuant to s. 287.057, designed
185	to facilitate the cost-effective purchase of a case-managed
186	continuum of care. The agency shall also require providers to
187	minimize the exposure of recipients to the need for acute
188	inpatient, custodial, and other institutional care and the
189	inappropriate or unnecessary use of high-cost services. The
190	agency shall contract with a vendor to monitor and evaluate the
191	clinical practice patterns of providers in order to identify
192	trends that are outside the normal practice patterns of a
193	provider's professional peers or the national guidelines of a
194	provider's professional association. The vendor must be able to
195	provide information and counseling to a provider whose practice
196	patterns are outside the norms, in consultation with the agency,
197	to improve patient care and reduce inappropriate utilization.
198	The agency may mandate prior authorization, drug therapy
199	management, or disease management participation for certain
200	populations of Medicaid beneficiaries, certain drug classes, or
201	particular drugs to prevent fraud, abuse, overuse, and possible
202	dangerous drug interactions. The Pharmaceutical and Therapeutics
203	Committee shall make recommendations to the agency on drugs for
204	which prior authorization is required. The agency shall inform
205	the Pharmaceutical and Therapeutics Committee of its decisions
206	regarding drugs subject to prior authorization. The agency is
207	authorized to limit the entities it contracts with or enrolls as
208	Medicaid providers by developing a provider network through
209	provider credentialing. The agency may competitively bid single-
210	source-provider contracts if procurement of goods or services
211	results in demonstrated cost savings to the state without
212	limiting access to care. The agency may limit its network based
213	on the assessment of beneficiary access to care, provider
214	availability, provider quality standards, time and distance
215	standards for access to care, the cultural competence of the
216	provider network, demographic characteristics of Medicaid
217	beneficiaries, practice and provider-to-beneficiary standards,
218	appointment wait times, beneficiary use of services, provider
219	turnover, provider profiling, provider licensure history,
220	previous program integrity investigations and findings, peer
221	review, provider Medicaid policy and billing compliance records,
222	clinical and medical record audits, and other factors. Providers
223	shall not be entitled to enrollment in the Medicaid provider
224	network. The agency shall determine instances in which allowing
225	Medicaid beneficiaries to purchase durable medical equipment and
226	other goods is less expensive to the Medicaid program than long-
227	term rental of the equipment or goods. The agency may establish
228	rules to facilitate purchases in lieu of long-term rentals in
229	order to protect against fraud and abuse in the Medicaid program
230	as defined in s. 409.913. The agency may seek federal waivers
231	necessary to administer these policies.
232	(4)  The agency may contract with:
233	(d)  A provider service network, which may be reimbursed on
234	a fee-for-service or prepaid basis. A provider service network
235	which is reimbursed by the agency on a prepaid basis shall be
236	exempt from parts I and III of chapter 641, but must comply with
237	the solvency requirements in s. 641.2261(2) and meet appropriate
238	financial reserve, quality assurance, and patient rights
239	requirements as established by the agency. The agency is
240	authorized to contract with specialty provider service networks
241	that exclusively enroll Medicaid recipients with psychiatric
242	disabilities.
243	1.  Except as provided in subparagraph 2., Medicaid
244	recipients assigned to a provider service network shall be
245	chosen equally from those who would otherwise have been assigned
246	to prepaid plans and MediPass. The agency is authorized to seek
247	federal Medicaid waivers as necessary to implement the
248	provisions of this section. Any contract previously awarded to a
249	provider service network operated by a hospital pursuant to this
250	subsection shall remain in effect for a period of 3 years
251	following the current contract expiration date, regardless of
252	any contractual provisions to the contrary. A provider service
253	network is a network established or organized and operated by a
254	health care provider, or group of affiliated health care
255	providers, including minority physician networks and emergency
256	room diversion programs that meet the requirements of s.
257	409.91211, which provides a substantial proportion of the health
258	care items and services under a contract directly through the
259	provider or affiliated group of providers and may make
260	arrangements with physicians or other health care professionals,
261	health care institutions, or any combination of such individuals
262	or institutions to assume all or part of the financial risk on a
263	prospective basis for the provision of basic health services by
264	the physicians, by other health professionals, or through the
265	institutions. The health care providers must have a controlling
266	interest in the governing body of the provider service network
267	organization.
268	2.  A Medicaid recipient with psychiatric disabilities who
269	fails to select a managed care plan shall be assigned to a
270	provider service network that exclusively enrolls Medicaid
271	recipients with psychiatric disabilities, if such program is
272	available in the geographic area where the recipient resides.
273	Section 3.  Paragraph (ee) is added to subsection (3) of
274	section 409.91211, Florida Statutes, and paragraph (a) of
275	subsection (4) of that section is amended, to read:
276	409.91211  Medicaid managed care pilot program.--
277	(3)  The agency shall have the following powers, duties,
278	and responsibilities with respect to the pilot program:
279	(ee)  To seek applications for and contract with provider
280	service networks specializing in care for recipients with
281	psychiatric disabilities. The agency shall develop and implement
282	a definition of psychiatric disabilities for membership and
283	assignment purposes and establish assignment processes for
284	recipients with psychiatric disabilities who fail to choose a
285	managed care plan.
286	(4)(a)  A Medicaid recipient in the pilot area who is not
287	currently enrolled in a capitated managed care plan upon
288	implementation is not eligible for services as specified in ss.
289	409.905 and 409.906, for the amount of time that the recipient
290	does not enroll in a capitated managed care network. If a
291	Medicaid recipient has not enrolled in a capitated managed care
292	plan within 30 days after eligibility, the agency shall assign
293	the Medicaid recipient to a capitated managed care plan based on
294	the assessed needs of the recipient as determined by the agency
295	and the recipient shall be exempt from s. 409.9122. When making
296	assignments, the agency shall take into account the following
297	criteria:
298	1.  A capitated managed care network has sufficient network
299	capacity to meet the needs of members.
300	2.  The capitated managed care network has previously
301	enrolled the recipient as a member, or one of the capitated
302	managed care network's primary care providers has previously
303	provided health care to the recipient.
304	3.  The agency has knowledge that the member has previously
305	expressed a preference for a particular capitated managed care
306	network as indicated by Medicaid fee-for-service claims data,
307	but has failed to make a choice.
308	4.  The capitated managed care network's primary care
309	providers are geographically accessible to the recipient's
310	residence.
311	5.  The existence of any known diagnoses or disabilities,
312	including psychiatric disabilities.
313	Section 4.  This act shall take effect July 1, 2007.

CODING: Words stricken are deletions; words underlined are additions.