Senate Bill sb0012Ce2

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    CS for SB 12-C                                Second Engrossed



  1                      A bill to be entitled

  2         An act relating to health care; amending s.

  3         393.0661, F.S.; providing for additional hours

  4         to be authorized under the personal care

  5         assistance services provided pursuant to a

  6         federal waiver program and administered by the

  7         Agency for Persons with Disabilities; amending

  8         a specified portion of proviso in Specific

  9         Appropriation 270 in chapter 2007-72, Laws of

10         Florida; amending s. 409.908, F.S.; deleting a

11         provision providing that an operator of a

12         Medicaid nursing home may qualify for an

13         increased reimbursement rate due to a change of

14         ownership or licensed operator; providing a

15         limitation on the reimbursement rates for

16         Medicaid payments to nursing homes; amending s.

17         409.912, F.S.; providing for certain children

18         who are eligible for Medicaid and who reside

19         within a specified service area of the Agency

20         for Health Care Administration to be served

21         under a service delivery mechanism other than

22         the HomeSafeNet system; amending s. 409.9122,

23         F.S.; requiring that the agency give certain

24         providers priority with respect to the

25         assignment of enrollees under the Medicaid

26         managed prepaid health plan; deleting a

27         requirement that certain recipients of

28         comprehensive behavioral health services be

29         assigned to MediPass or a managed care plan;

30         amending s. 409.91211, F.S.; clarifying the

31         duties of the agency for implementing service


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    CS for SB 12-C                                Second Engrossed



 1         delivery mechanisms for certain children who

 2         are eligible for Medicaid; providing effective

 3         dates.

 4  

 5  Be It Enacted by the Legislature of the State of Florida:

 6  

 7         Section 1.  Paragraph (f) of subsection (3) of section

 8  393.0661, Florida Statutes, is amended to read:

 9         393.0661  Home and community-based services delivery

10  system; comprehensive redesign.--The Legislature finds that

11  the home and community-based services delivery system for

12  persons with developmental disabilities and the availability

13  of appropriated funds are two of the critical elements in

14  making services available. Therefore, it is the intent of the

15  Legislature that the Agency for Persons with Disabilities

16  shall develop and implement a comprehensive redesign of the

17  system.

18         (3)  The Agency for Health Care Administration, in

19  consultation with the agency, shall seek federal approval and

20  implement a four-tiered waiver system to serve clients with

21  developmental disabilities in the developmental disabilities

22  and family and supported living waivers. The agency shall

23  assign all clients receiving services through the

24  developmental disabilities waiver to a tier based on a valid

25  assessment instrument, client characteristics, and other

26  appropriate assessment methods. All services covered under the

27  current developmental disabilities waiver shall be available

28  to all clients in all tiers where appropriate, except as

29  otherwise provided in this subsection or in the General

30  Appropriations Act.

31  


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    CS for SB 12-C                                Second Engrossed



 1         (f)  The agency shall seek federal waivers and amend

 2  contracts as necessary to make changes to services defined in

 3  federal waiver programs administered by the agency as follows:

 4         1.  Supported living coaching services shall not exceed

 5  20 hours per month for persons who also receive in-home

 6  support services.

 7         2.  Limited support coordination services shall be the

 8  only type of support coordination service provided to persons

 9  under the age of 18 who live in the family home.

10         3.  Personal care assistance services shall be limited

11  to no more than 180 hours per calendar month and shall not

12  include rate modifiers. Additional hours may be authorized for

13  persons who have intensive physical, medical, or adaptive

14  needs if such hours are essential for avoiding

15  institutionalization only if a substantial change in

16  circumstances occurs for the individual.

17         4.  Residential habilitation services shall be limited

18  to 8 hours per day. Additional hours may be authorized for

19  persons who have intensive medical or adaptive needs and if

20  such hours are essential for avoiding institutionalization, or

21  for persons who possess behavioral problems that are

22  exceptional in intensity, duration, or frequency and present a

23  substantial risk of harming themselves or others. This

24  restriction shall be in effect until the four-tiered waiver

25  system is fully implemented.

26         5.  Chore Services, nonresidential support services,

27  and homemaker services shall be eliminated. The agency shall

28  expand the definition of in-home support services to enable

29  the provider of the service to include activities previously

30  provided in these eliminated services.

31  


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    CS for SB 12-C                                Second Engrossed



 1         6.  Massage therapy and psychological assessment

 2  services shall be eliminated.

 3         7.  The agency shall conduct supplemental cost plan

 4  reviews to verify the medical necessity of authorized services

 5  for plans that have increased by more than 8 percent during

 6  either of the 2 preceding fiscal years.

 7         8.  The agency shall implement a consolidated

 8  residential habilitation rate structure to increase savings to

 9  the state through a more cost-effective payment method and

10  establish uniform rates for intensive behavioral residential

11  habilitation services.

12         9.  Pending federal approval, the agency is authorized

13  to extend current support plans for clients receiving services

14  under Medicaid waivers for 1 year beginning July 1, 2007, or

15  from the date approved, whichever is later. Clients who have a

16  substantial change in circumstances which threatens their

17  health and safety may be reassessed during this year in order

18  to determine the necessity for a change in their support plan.

19         Section 2.  The following proviso associated with

20  Specific Appropriation 270 in chapter 2007-72, Laws of

21  Florida, is amended to read:

22         Personal Care Assistance services shall be limited to

23  no more than 180 hours per calendar month and shall not

24  include rate modifiers. Additional hours may be authorized for

25  persons who have intensive physical, medical, or adaptive

26  needs if such hours are essential for avoiding

27  institutionalization only if a substantial change in

28  circumstances occurs for the individual.

29         Section 3.  Paragraph (b) of subsection (2) and

30  paragraph (d) of subsection (13) of section 409.908, Florida

31  Statutes, are amended to read:


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    CS for SB 12-C                                Second Engrossed



 1         409.908  Reimbursement of Medicaid providers.--Subject

 2  to specific appropriations, the agency shall reimburse

 3  Medicaid providers, in accordance with state and federal law,

 4  according to methodologies set forth in the rules of the

 5  agency and in policy manuals and handbooks incorporated by

 6  reference therein.  These methodologies may include fee

 7  schedules, reimbursement methods based on cost reporting,

 8  negotiated fees, competitive bidding pursuant to s. 287.057,

 9  and other mechanisms the agency considers efficient and

10  effective for purchasing services or goods on behalf of

11  recipients. If a provider is reimbursed based on cost

12  reporting and submits a cost report late and that cost report

13  would have been used to set a lower reimbursement rate for a

14  rate semester, then the provider's rate for that semester

15  shall be retroactively calculated using the new cost report,

16  and full payment at the recalculated rate shall be effected

17  retroactively. Medicare-granted extensions for filing cost

18  reports, if applicable, shall also apply to Medicaid cost

19  reports. Payment for Medicaid compensable services made on

20  behalf of Medicaid eligible persons is subject to the

21  availability of moneys and any limitations or directions

22  provided for in the General Appropriations Act or chapter 216.

23  Further, nothing in this section shall be construed to prevent

24  or limit the agency from adjusting fees, reimbursement rates,

25  lengths of stay, number of visits, or number of services, or

26  making any other adjustments necessary to comply with the

27  availability of moneys and any limitations or directions

28  provided for in the General Appropriations Act, provided the

29  adjustment is consistent with legislative intent.

30         (2)

31  


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    CS for SB 12-C                                Second Engrossed



 1         (b)  Subject to any limitations or directions provided

 2  for in the General Appropriations Act, the agency shall

 3  establish and implement a Florida Title XIX Long-Term Care

 4  Reimbursement Plan (Medicaid) for nursing home care in order

 5  to provide care and services in conformance with the

 6  applicable state and federal laws, rules, regulations, and

 7  quality and safety standards and to ensure that individuals

 8  eligible for medical assistance have reasonable geographic

 9  access to such care.

10         1.  Changes of ownership or of licensed operator may or

11  may not qualify for increases in reimbursement rates

12  associated with the change of ownership or of licensed

13  operator. The agency may amend the Title XIX Long Term Care

14  Reimbursement Plan to provide that the initial nursing home

15  reimbursement rates, for the operating, patient care, and MAR

16  components, associated with related and unrelated party

17  changes of ownership or licensed operator filed on or after

18  September 1, 2001, are equivalent to the previous owner's

19  reimbursement rate.

20         1.2.  The agency shall amend the long-term care

21  reimbursement plan and cost reporting system to create direct

22  care and indirect care subcomponents of the patient care

23  component of the per diem rate. These two subcomponents

24  together shall equal the patient care component of the per

25  diem rate. Separate cost-based ceilings shall be calculated

26  for each patient care subcomponent. The direct care

27  subcomponent of the per diem rate shall be limited by the

28  cost-based class ceiling, and the indirect care subcomponent

29  may be limited by the lower of the cost-based class ceiling,

30  the target rate class ceiling, or the individual provider

31  target.


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    CS for SB 12-C                                Second Engrossed



 1         2.3.  The direct care subcomponent shall include

 2  salaries and benefits of direct care staff providing nursing

 3  services including registered nurses, licensed practical

 4  nurses, and certified nursing assistants who deliver care

 5  directly to residents in the nursing home facility. This

 6  excludes nursing administration, minimum data set, and care

 7  plan coordinators, staff development, and staffing

 8  coordinator.

 9         3.4.  All other patient care costs shall be included in

10  the indirect care cost subcomponent of the patient care per

11  diem rate. There shall be no costs directly or indirectly

12  allocated to the direct care subcomponent from a home office

13  or management company.

14         4.5.  On July 1 of each year, the agency shall report

15  to the Legislature direct and indirect care costs, including

16  average direct and indirect care costs per resident per

17  facility and direct care and indirect care salaries and

18  benefits per category of staff member per facility.

19         5.6.  In order to offset the cost of general and

20  professional liability insurance, the agency shall amend the

21  plan to allow for interim rate adjustments to reflect

22  increases in the cost of general or professional liability

23  insurance for nursing homes. This provision shall be

24  implemented to the extent existing appropriations are

25  available.

26  

27  It is the intent of the Legislature that the reimbursement

28  plan achieve the goal of providing access to health care for

29  nursing home residents who require large amounts of care while

30  encouraging diversion services as an alternative to nursing

31  home care for residents who can be served within the


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    CS for SB 12-C                                Second Engrossed



 1  community. The agency shall base the establishment of any

 2  maximum rate of payment, whether overall or component, on the

 3  available moneys as provided for in the General Appropriations

 4  Act. The agency may base the maximum rate of payment on the

 5  results of scientifically valid analysis and conclusions

 6  derived from objective statistical data pertinent to the

 7  particular maximum rate of payment.

 8         (13)  Medicare premiums for persons eligible for both

 9  Medicare and Medicaid coverage shall be paid at the rates

10  established by Title XVIII of the Social Security Act.  For

11  Medicare services rendered to Medicaid-eligible persons,

12  Medicaid shall pay Medicare deductibles and coinsurance as

13  follows:

14         (d)  Notwithstanding paragraphs (a)-(c):

15         1.  Medicaid payments for Nursing Home Medicare part A

16  coinsurance shall be limited to the lesser of the Medicare

17  coinsurance amount or the Medicaid nursing home per diem rate

18  less any amounts paid by Medicare, but only up to the amount

19  of Medicare coinsurance. The Medicaid per diem rate shall be

20  the rate in effect for the dates of service of the crossover

21  claims and may not be subsequently adjusted due to subsequent

22  per diem rate adjustments.

23         2.  Medicaid shall pay all deductibles and coinsurance

24  for Medicare-eligible recipients receiving freestanding end

25  stage renal dialysis center services.

26         3.  Medicaid payments for general hospital inpatient

27  services shall be limited to the Medicare deductible per spell

28  of illness.  Medicaid shall make no payment toward coinsurance

29  for Medicare general hospital inpatient services.

30  

31  


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    CS for SB 12-C                                Second Engrossed



 1         4.  Medicaid shall pay all deductibles and coinsurance

 2  for Medicare emergency transportation services provided by

 3  ambulances licensed pursuant to chapter 401.

 4         Section 4.  Paragraph (b) of subsection (4) of section

 5  409.912, Florida Statutes, is amended to read:

 6         409.912  Cost-effective purchasing of health care.--The

 7  agency shall purchase goods and services for Medicaid

 8  recipients in the most cost-effective manner consistent with

 9  the delivery of quality medical care. To ensure that medical

10  services are effectively utilized, the agency may, in any

11  case, require a confirmation or second physician's opinion of

12  the correct diagnosis for purposes of authorizing future

13  services under the Medicaid program. This section does not

14  restrict access to emergency services or poststabilization

15  care services as defined in 42 C.F.R. part 438.114. Such

16  confirmation or second opinion shall be rendered in a manner

17  approved by the agency. The agency shall maximize the use of

18  prepaid per capita and prepaid aggregate fixed-sum basis

19  services when appropriate and other alternative service

20  delivery and reimbursement methodologies, including

21  competitive bidding pursuant to s. 287.057, designed to

22  facilitate the cost-effective purchase of a case-managed

23  continuum of care. The agency shall also require providers to

24  minimize the exposure of recipients to the need for acute

25  inpatient, custodial, and other institutional care and the

26  inappropriate or unnecessary use of high-cost services. The

27  agency shall contract with a vendor to monitor and evaluate

28  the clinical practice patterns of providers in order to

29  identify trends that are outside the normal practice patterns

30  of a provider's professional peers or the national guidelines

31  of a provider's professional association. The vendor must be


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    CS for SB 12-C                                Second Engrossed



 1  able to provide information and counseling to a provider whose

 2  practice patterns are outside the norms, in consultation with

 3  the agency, to improve patient care and reduce inappropriate

 4  utilization. The agency may mandate prior authorization, drug

 5  therapy management, or disease management participation for

 6  certain populations of Medicaid beneficiaries, certain drug

 7  classes, or particular drugs to prevent fraud, abuse, overuse,

 8  and possible dangerous drug interactions. The Pharmaceutical

 9  and Therapeutics Committee shall make recommendations to the

10  agency on drugs for which prior authorization is required. The

11  agency shall inform the Pharmaceutical and Therapeutics

12  Committee of its decisions regarding drugs subject to prior

13  authorization. The agency is authorized to limit the entities

14  it contracts with or enrolls as Medicaid providers by

15  developing a provider network through provider credentialing.

16  The agency may competitively bid single-source-provider

17  contracts if procurement of goods or services results in

18  demonstrated cost savings to the state without limiting access

19  to care. The agency may limit its network based on the

20  assessment of beneficiary access to care, provider

21  availability, provider quality standards, time and distance

22  standards for access to care, the cultural competence of the

23  provider network, demographic characteristics of Medicaid

24  beneficiaries, practice and provider-to-beneficiary standards,

25  appointment wait times, beneficiary use of services, provider

26  turnover, provider profiling, provider licensure history,

27  previous program integrity investigations and findings, peer

28  review, provider Medicaid policy and billing compliance

29  records, clinical and medical record audits, and other

30  factors. Providers shall not be entitled to enrollment in the

31  Medicaid provider network. The agency shall determine


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    CS for SB 12-C                                Second Engrossed



 1  instances in which allowing Medicaid beneficiaries to purchase

 2  durable medical equipment and other goods is less expensive to

 3  the Medicaid program than long-term rental of the equipment or

 4  goods. The agency may establish rules to facilitate purchases

 5  in lieu of long-term rentals in order to protect against fraud

 6  and abuse in the Medicaid program as defined in s. 409.913.

 7  The agency may seek federal waivers necessary to administer

 8  these policies.

 9         (4)  The agency may contract with:

10         (b)  An entity that is providing comprehensive

11  behavioral health care services to certain Medicaid recipients

12  through a capitated, prepaid arrangement pursuant to the

13  federal waiver provided for by s. 409.905(5). Such an entity

14  must be licensed under chapter 624, chapter 636, or chapter

15  641 and must possess the clinical systems and operational

16  competence to manage risk and provide comprehensive behavioral

17  health care to Medicaid recipients. As used in this paragraph,

18  the term "comprehensive behavioral health care services" means

19  covered mental health and substance abuse treatment services

20  that are available to Medicaid recipients. The secretary of

21  the Department of Children and Family Services shall approve

22  provisions of procurements related to children in the

23  department's care or custody prior to enrolling such children

24  in a prepaid behavioral health plan. Any contract awarded

25  under this paragraph must be competitively procured. In

26  developing the behavioral health care prepaid plan procurement

27  document, the agency shall ensure that the procurement

28  document requires the contractor to develop and implement a

29  plan to ensure compliance with s. 394.4574 related to services

30  provided to residents of licensed assisted living facilities

31  that hold a limited mental health license. Except as provided


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    CS for SB 12-C                                Second Engrossed



 1  in subparagraph 8., and except in counties where the Medicaid

 2  managed care pilot program is authorized pursuant to s.

 3  409.91211, the agency shall seek federal approval to contract

 4  with a single entity meeting these requirements to provide

 5  comprehensive behavioral health care services to all Medicaid

 6  recipients not enrolled in a Medicaid managed care plan

 7  authorized under s. 409.91211 or a Medicaid health maintenance

 8  organization in an AHCA area. In an AHCA area where the

 9  Medicaid managed care pilot program is authorized pursuant to

10  s. 409.91211 in one or more counties, the agency may procure a

11  contract with a single entity to serve the remaining counties

12  as an AHCA area or the remaining counties may be included with

13  an adjacent AHCA area and shall be subject to this paragraph.

14  Each entity must offer sufficient choice of providers in its

15  network to ensure recipient access to care and the opportunity

16  to select a provider with whom they are satisfied. The network

17  shall include all public mental health hospitals. To ensure

18  unimpaired access to behavioral health care services by

19  Medicaid recipients, all contracts issued pursuant to this

20  paragraph shall require 80 percent of the capitation paid to

21  the managed care plan, including health maintenance

22  organizations, to be expended for the provision of behavioral

23  health care services. In the event the managed care plan

24  expends less than 80 percent of the capitation paid pursuant

25  to this paragraph for the provision of behavioral health care

26  services, the difference shall be returned to the agency. The

27  agency shall provide the managed care plan with a

28  certification letter indicating the amount of capitation paid

29  during each calendar year for the provision of behavioral

30  health care services pursuant to this section. The agency may

31  reimburse for substance abuse treatment services on a


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    CS for SB 12-C                                Second Engrossed



 1  fee-for-service basis until the agency finds that adequate

 2  funds are available for capitated, prepaid arrangements.

 3         1.  By January 1, 2001, the agency shall modify the

 4  contracts with the entities providing comprehensive inpatient

 5  and outpatient mental health care services to Medicaid

 6  recipients in Hillsborough, Highlands, Hardee, Manatee, and

 7  Polk Counties, to include substance abuse treatment services.

 8         2.  By July 1, 2003, the agency and the Department of

 9  Children and Family Services shall execute a written agreement

10  that requires collaboration and joint development of all

11  policy, budgets, procurement documents, contracts, and

12  monitoring plans that have an impact on the state and Medicaid

13  community mental health and targeted case management programs.

14         3.  Except as provided in subparagraph 8., by July 1,

15  2006, the agency and the Department of Children and Family

16  Services shall contract with managed care entities in each

17  AHCA area except area 6 or arrange to provide comprehensive

18  inpatient and outpatient mental health and substance abuse

19  services through capitated prepaid arrangements to all

20  Medicaid recipients who are eligible to participate in such

21  plans under federal law and regulation. In AHCA areas where

22  eligible individuals number less than 150,000, the agency

23  shall contract with a single managed care plan to provide

24  comprehensive behavioral health services to all recipients who

25  are not enrolled in a Medicaid health maintenance organization

26  or a Medicaid capitated managed care plan authorized under s.

27  409.91211. The agency may contract with more than one

28  comprehensive behavioral health provider to provide care to

29  recipients who are not enrolled in a Medicaid capitated

30  managed care plan authorized under s. 409.91211 or a Medicaid

31  health maintenance organization in AHCA areas where the


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    CS for SB 12-C                                Second Engrossed



 1  eligible population exceeds 150,000. In an AHCA area where the

 2  Medicaid managed care pilot program is authorized pursuant to

 3  s. 409.91211 in one or more counties, the agency may procure a

 4  contract with a single entity to serve the remaining counties

 5  as an AHCA area or the remaining counties may be included with

 6  an adjacent AHCA area and shall be subject to this paragraph.

 7  Contracts for comprehensive behavioral health providers

 8  awarded pursuant to this section shall be competitively

 9  procured. Both for-profit and not-for-profit corporations

10  shall be eligible to compete. Managed care plans contracting

11  with the agency under subsection (3) shall provide and receive

12  payment for the same comprehensive behavioral health benefits

13  as provided in AHCA rules, including handbooks incorporated by

14  reference. In AHCA area 11, the agency shall contract with at

15  least two comprehensive behavioral health care providers to

16  provide behavioral health care to recipients in that area who

17  are enrolled in, or assigned to, the MediPass program. One of

18  the behavioral health care contracts shall be with the

19  existing provider service network pilot project, as described

20  in paragraph (d), for the purpose of demonstrating the

21  cost-effectiveness of the provision of quality mental health

22  services through a public hospital-operated managed care

23  model. Payment shall be at an agreed-upon capitated rate to

24  ensure cost savings. Of the recipients in area 11 who are

25  assigned to MediPass under the provisions of s.

26  409.9122(2)(k), a minimum of 50,000 of those MediPass-enrolled

27  recipients shall be assigned to the existing provider service

28  network in area 11 for their behavioral care.

29         4.  By October 1, 2003, the agency and the department

30  shall submit a plan to the Governor, the President of the

31  Senate, and the Speaker of the House of Representatives which


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    CS for SB 12-C                                Second Engrossed



 1  provides for the full implementation of capitated prepaid

 2  behavioral health care in all areas of the state.

 3         a.  Implementation shall begin in 2003 in those AHCA

 4  areas of the state where the agency is able to establish

 5  sufficient capitation rates.

 6         b.  If the agency determines that the proposed

 7  capitation rate in any area is insufficient to provide

 8  appropriate services, the agency may adjust the capitation

 9  rate to ensure that care will be available. The agency and the

10  department may use existing general revenue to address any

11  additional required match but may not over-obligate existing

12  funds on an annualized basis.

13         c.  Subject to any limitations provided for in the

14  General Appropriations Act, the agency, in compliance with

15  appropriate federal authorization, shall develop policies and

16  procedures that allow for certification of local and state

17  funds.

18         5.  Children residing in a statewide inpatient

19  psychiatric program, or in a Department of Juvenile Justice or

20  a Department of Children and Family Services residential

21  program approved as a Medicaid behavioral health overlay

22  services provider shall not be included in a behavioral health

23  care prepaid health plan or any other Medicaid managed care

24  plan pursuant to this paragraph.

25         6.  In converting to a prepaid system of delivery, the

26  agency shall in its procurement document require an entity

27  providing only comprehensive behavioral health care services

28  to prevent the displacement of indigent care patients by

29  enrollees in the Medicaid prepaid health plan providing

30  behavioral health care services from facilities receiving

31  state funding to provide indigent behavioral health care, to


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    CS for SB 12-C                                Second Engrossed



 1  facilities licensed under chapter 395 which do not receive

 2  state funding for indigent behavioral health care, or

 3  reimburse the unsubsidized facility for the cost of behavioral

 4  health care provided to the displaced indigent care patient.

 5         7.  Traditional community mental health providers under

 6  contract with the Department of Children and Family Services

 7  pursuant to part IV of chapter 394, child welfare providers

 8  under contract with the Department of Children and Family

 9  Services in areas 1 and 6, and inpatient mental health

10  providers licensed pursuant to chapter 395 must be offered an

11  opportunity to accept or decline a contract to participate in

12  any provider network for prepaid behavioral health services.

13         8.  For fiscal year 2004-2005, all Medicaid eligible

14  children, except children in areas 1 and 6, whose cases are

15  open for child welfare services in the HomeSafeNet system,

16  shall be enrolled in MediPass or in Medicaid fee-for-service

17  and all their behavioral health care services including

18  inpatient, outpatient psychiatric, community mental health,

19  and case management shall be reimbursed on a fee-for-service

20  basis. Beginning July 1, 2005, such children, who are open for

21  child welfare services in the HomeSafeNet system, shall

22  receive their behavioral health care services through a

23  specialty prepaid plan operated by community-based lead

24  agencies either through a single agency or formal agreements

25  among several agencies. The specialty prepaid plan must result

26  in savings to the state comparable to savings achieved in

27  other Medicaid managed care and prepaid programs. Such plan

28  must provide mechanisms to maximize state and local revenues.

29  The specialty prepaid plan shall be developed by the agency

30  and the Department of Children and Family Services. The agency

31  is authorized to seek any federal waivers to implement this


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    CS for SB 12-C                                Second Engrossed



 1  initiative. Medicaid-eligible children whose cases are open

 2  for child welfare services in the HomeSafeNet system and who

 3  reside in AHCA area 10 are exempt from the specialty prepaid

 4  plan upon the development of a service delivery mechanism for

 5  children who reside in area 10 as specified in s.

 6  409.91211(3)(dd).

 7         Section 5.  Subsection (13) of section 409.9122,

 8  Florida Statutes, is amended to read:

 9         409.9122  Mandatory Medicaid managed care enrollment;

10  programs and procedures.--

11         (13)  Effective July 1, 2003, the agency shall adjust

12  the enrollee assignment process of Medicaid managed prepaid

13  health plans for those Medicaid managed prepaid plans

14  operating in Miami-Dade County which have executed a contract

15  with the agency for a minimum of 8 consecutive years in order

16  for the Medicaid managed prepaid plan to maintain a minimum

17  enrollment level of 15,000 members per month. When assigning

18  enrollees pursuant to this subsection, the agency shall give

19  priority to providers that initially qualified under this

20  subsection until such providers reach and maintain an

21  enrollment level of 15,000 members per month. A prepaid health

22  plan that has a statewide Medicaid enrollment of 25,000 or

23  more members is not eligible for enrollee assignments under

24  this subsection.

25         Section 6.  Effective March 1, 2008, paragraph (k) of

26  subsection (2) of section 409.9122, Florida Statutes, is

27  amended to read:

28         409.9122  Mandatory Medicaid managed care enrollment;

29  programs and procedures.--

30         (2)

31  


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    CS for SB 12-C                                Second Engrossed



 1         (k)  When a Medicaid recipient does not choose a

 2  managed care plan or MediPass provider, the agency shall

 3  assign the Medicaid recipient to a managed care plan, except

 4  in those counties in which there are fewer than two managed

 5  care plans accepting Medicaid enrollees, in which case

 6  assignment shall be to a managed care plan or a MediPass

 7  provider. Medicaid recipients in counties with fewer than two

 8  managed care plans accepting Medicaid enrollees who are

 9  subject to mandatory assignment but who fail to make a choice

10  shall be assigned to managed care plans until an enrollment of

11  35 percent in MediPass and 65 percent in managed care plans,

12  of all those eligible to choose managed care, is achieved.

13  Once that enrollment is achieved, the assignments shall be

14  divided in order to maintain an enrollment in MediPass and

15  managed care plans which is in a 35 percent and 65 percent

16  proportion, respectively. In service areas 1 and 6 of the

17  Agency for Health Care Administration where the agency is

18  contracting for the provision of comprehensive behavioral

19  health services through a capitated prepaid arrangement,

20  recipients who fail to make a choice shall be assigned equally

21  to MediPass or a managed care plan. For purposes of this

22  paragraph, when referring to assignment, the term "managed

23  care plans" includes exclusive provider organizations,

24  provider service networks, Children's Medical Services

25  Network, minority physician networks, and pediatric emergency

26  department diversion programs authorized by this chapter or

27  the General Appropriations Act. When making assignments, the

28  agency shall take into account the following criteria:

29         1.  A managed care plan has sufficient network capacity

30  to meet the need of members.

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    CS for SB 12-C                                Second Engrossed



 1         2.  The managed care plan or MediPass has previously

 2  enrolled the recipient as a member, or one of the managed care

 3  plan's primary care providers or MediPass providers has

 4  previously provided health care to the recipient.

 5         3.  The agency has knowledge that the member has

 6  previously expressed a preference for a particular managed

 7  care plan or MediPass provider as indicated by Medicaid

 8  fee-for-service claims data, but has failed to make a choice.

 9         4.  The managed care plan's or MediPass primary care

10  providers are geographically accessible to the recipient's

11  residence.

12         5.  The agency has authority to make mandatory

13  assignments based on quality of service and performance of

14  managed care plans.

15         Section 7.  Paragraph (dd) of subsection (3) of section

16  409.91211, Florida Statutes, is amended to read:

17         409.91211  Medicaid managed care pilot program.--

18         (3)  The agency shall have the following powers,

19  duties, and responsibilities with respect to the pilot

20  program:

21         (dd)  To implement develop and recommend service

22  delivery mechanisms within capitated managed care plans to

23  provide Medicaid services as specified in ss. 409.905 and

24  409.906 to Medicaid-eligible children whose cases are open for

25  child welfare services in the HomeSafeNet system in foster

26  care. These services must be coordinated with community-based

27  care providers as specified in s. 409.1671 s. 409.1675, where

28  available, and be sufficient to meet the medical,

29  developmental, behavioral, and emotional needs of these

30  children. These service delivery mechanisms must be

31  implemented no later than July 1, 2008, in AHCA area 10 in


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    CS for SB 12-C                                Second Engrossed



 1  order for the children in AHCA area 10 to remain exempt from

 2  the statewide plan under s. 409.912(4)(b)8.

 3         Section 8.  Except as otherwise expressly provided in

 4  this act, this act shall take effect upon becoming a law.

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