CS for CS for SB 1484 Second Engrossed
20101484e2
1 A bill to be entitled
2 An act relating to Medicaid; requiring that the Agency
3 for Health Care Administration request an extension of
4 a specified federal waiver; requiring the agency to
5 report each month to the Legislature; requiring that
6 certain changes of terms and conditions relating to
7 the low-income pool be approved by the Legislative
8 Budget Commission; requiring that the agency develop a
9 methodology for intergovernmental transfers in any
10 expansion of prepaid managed care in the Medicaid
11 program; requiring that the secretary appoint a
12 technical advisory panel; requiring a report to the
13 Governor and Legislature; creating s. 624.35, F.S.;
14 providing a short title; creating s. 624.351, F.S.;
15 providing legislative findings; establishing the
16 Medicaid and Public Assistance Fraud Strike Force
17 within the Department of Financial Services to
18 coordinate efforts to eliminate Medicaid and public
19 assistance fraud; providing for membership; providing
20 for meetings; specifying duties; requiring an annual
21 report to the Legislature and Governor; creating s.
22 624.352, F.S.; directing the Chief Financial Officer
23 to prepare model interagency agreements that address
24 Medicaid and public assistance fraud; specifying which
25 agencies may be a party to such agreements; amending
26 s. 16.59, F.S.; conforming provisions to changes made
27 by the act; requiring the Divisions of Insurance Fraud
28 and Public Assistance Fraud in the Department of
29 Financial Services to be collocated with the Medicaid
30 Fraud Control Unit if possible; requiring positions
31 dedicated to Medicaid managed care fraud to be
32 collocated with the Division of Insurance Fraud;
33 amending s. 20.121, F.S.; establishing the Division of
34 Public Assistance Fraud within the Department of
35 Financial Services; amending ss. 411.01, 414.33, and
36 414.39, F.S.; conforming provisions to changes made by
37 the act; transferring, renumbering, and amending s.
38 943.401, F.S.; directing the Department of Financial
39 Services rather than the Department of Law Enforcement
40 to investigate public assistance fraud; creating s.
41 409.91212, F.S.; requiring that each managed care plan
42 adopt an anti-fraud plan; specifying requirements for
43 the plan; requiring that a managed care plan providing
44 Medicaid services to establish and maintain a fraud
45 investigative unit or contract for such services;
46 providing requirements for reports to the Office of
47 Medicaid Program Integrity; authorizing the agency to
48 impose fines against a managed care plan that fails to
49 submit an anti-fraud plan or make certain reports;
50 authorizing the agency to adopt rules; directing the
51 Auditor General and the Office of Program Policy
52 Analysis and Government Accountability to review the
53 Medicaid fraud and abuse processes in the Agency for
54 Health Care Administration; requiring a report to the
55 Legislature and Governor by a certain date;
56 establishing the Medicaid claims adjudication project
57 in the Agency for Health Care Administration to
58 decrease the incidence of inaccurate payments and to
59 improve the efficiency of the Medicaid claims
60 processing system; amending s. 409.912, F.S.;
61 authorizing the Agency for Health Care Administration
62 to contract with an entity that provides comprehensive
63 behavioral health care services to certain Medicaid
64 recipients who are not enrolled in a Medicaid managed
65 care plan or a Medicaid provider service network under
66 certain circumstances; amending s. 409.91211, F.S.;
67 revising certain provisions governing the Medicaid
68 managed care pilot program to conform to the extension
69 of the federal waiver; authorizing an administrative
70 fee to be paid to the specialty plan for the
71 coordination of services; transferring activities
72 relating to public assistance fraud from the
73 Department of Law Enforcement to the Division of
74 Public Assistance Fraud in the Department of Financial
75 Services by a type two transfer; providing effective
76 dates.
77
78 Be It Enacted by the Legislature of the State of Florida:
79
80 Section 1. By July 1, 2010, the Agency for Health Care
81 Administration shall begin the process of requesting an
82 extension of the Section 1115 waiver and shall ensure that the
83 waiver remains active and current. The agency shall report at
84 least monthly to the Legislature on progress in negotiating for
85 the extension of the waiver. Changes to the terms and conditions
86 relating to the low-income pool must be approved by the
87 Legislative Budget Commission.
88 Section 2. (1) The Agency for Health Care Administration
89 shall develop a methodology to ensure the availability of
90 intergovernmental transfers in any expansion of prepaid managed
91 care in the Medicaid program. The purpose of this methodology is
92 to support providers that have historically served Medicaid
93 recipients, including, but not limited to, safety net providers,
94 trauma hospitals, children’s hospitals, statutory teaching
95 hospitals, and medical and osteopathic physicians employed by or
96 under contract with a medical school in this state. The agency
97 may develop a supplemental capitation rate, risk pool, or
98 incentive payment to plans that contract with these providers.
99 The agency may develop the supplemental capitation rate to
100 consider rates higher than the fee-for-service Medicaid rate
101 when needed to ensure access and supported by funds provided by
102 a locality. The agency shall evaluate the development of the
103 rate cell to accurately reflect the underlying utilization to
104 the maximum extent possible. The methodology may include interim
105 rate adjustments as permitted under federal regulations. Any
106 such methodology shall preserve federal funding to these
107 entities and must be actuarially sound.
108 (2) The Secretary of Health Care Administration shall
109 appoint members and convene a technical advisory panel to advise
110 the agency in the study and development of intergovernmental
111 transfer distribution methods. The panel shall include
112 representatives from contributing hospitals, medical schools,
113 local governments, and managed care plans. The panel shall
114 advise the agency regarding the best methods for ensuring the
115 continued availability of intergovernmental transfers, specific
116 issues to resolve in negotiations with the Centers for Medicare
117 and Medicaid, and appropriate safeguards for appropriate
118 implementation of any developed payment methodologies.
119 (3) By January 1, 2011, the agency shall provide a report
120 to the Speaker of the House of Representatives, the President of
121 the Senate, and the Governor on the intergovernmental transfer
122 methodologies developed. The agency shall not implement such
123 methodologies without express legislative authority.
124 Section 3. Section 624.35, Florida Statutes, is created to
125 read:
126 624.35 Short title.—Sections 624.35-624.352 may be cited as
127 the “Medicaid and Public Assistance Fraud Strike Force Act.”
128 Section 4. Section 624.351, Florida Statutes, is created to
129 read:
130 624.351 Medicaid and Public Assistance Fraud Strike Force.—
131 (1) LEGISLATIVE FINDINGS.—The Legislature finds that there
132 is a need to develop and implement a statewide strategy to
133 coordinate state and local agencies, law enforcement entities,
134 and investigative units in order to increase the effectiveness
135 of programs and initiatives dealing with the prevention,
136 detection, and prosecution of Medicaid and public assistance
137 fraud.
138 (2) ESTABLISHMENT.—The Medicaid and Public Assistance Fraud
139 Strike Force is created within the department to oversee and
140 coordinate state and local efforts to eliminate Medicaid and
141 public assistance fraud and to recover state and federal funds.
142 The strike force shall serve in an advisory capacity and provide
143 recommendations and policy alternatives to the Chief Financial
144 Officer.
145 (3) MEMBERSHIP.—The strike force shall consist of the
146 following 11 members who may not designate anyone to serve in
147 their place:
148 (a) The Chief Financial Officer, who shall serve as chair.
149 (b) The Attorney General, who shall serve as vice chair.
150 (c) The executive director of the Department of Law
151 Enforcement.
152 (d) The Secretary of Health Care Administration.
153 (e) The Secretary of Children and Family Services.
154 (f) The State Surgeon General.
155 (g) Five members appointed by the Chief Financial Officer,
156 consisting of two sheriffs, two chiefs of police, and one state
157 attorney. When making these appointments, the Chief Financial
158 Officer shall consider representation by geography, population,
159 ethnicity, and other relevant factors in order to ensure that
160 the membership of the strike force is representative of the
161 state as a whole.
162 (4) TERMS OF MEMBERSHIP; COMPENSATION; STAFF.—
163 (a) The five members appointed by the Chief Financial
164 Officer shall be appointed to 4-year terms; however, for the
165 purpose of providing staggered terms, of the initial
166 appointments, two members shall be appointed to a 2-year term,
167 two members shall be appointed to a 3-year term, and one member
168 shall be appointed to a 4-year term. Each of the remaining
169 members is a standing member of the strike force and may not
170 serve beyond the time he or she holds the position that was the
171 basis for strike force membership. A vacancy shall be filled in
172 the same manner as the original appointment but only for the
173 unexpired term.
174 (b) The Legislature finds that the strike force serves a
175 legitimate state, county, and municipal purpose and that service
176 on the strike force is consistent with a member’s principal
177 service in a public office or employment. Therefore membership
178 on the strike force does not disqualify a member from holding
179 any other public office or from being employed by a public
180 entity, except that a member of the Legislature may not serve on
181 the strike force.
182 (c) Members of the strike force shall serve without
183 compensation, but are entitled to reimbursement for per diem and
184 travel expenses pursuant to s. 112.061. Reimbursements may be
185 paid from appropriations provided to the department by the
186 Legislature for the purposes of this section.
187 (d) The Chief Financial Officer shall appoint a chief of
188 staff for the strike force who must have experience, education,
189 and expertise in the fields of law, prosecution, or fraud
190 investigations and shall serve at the pleasure of the Chief
191 Financial Officer. The department shall provide the strike force
192 with staff necessary to assist the strike force in the
193 performance of its duties.
194 (5) MEETINGS.—The strike force shall hold its
195 organizational session by March 1, 2011. Thereafter, the strike
196 force shall meet at least four times per year. Additional
197 meetings may be held if the chair determines that extraordinary
198 circumstances require an additional meeting. Members may appear
199 by electronic means. A majority of the members of the strike
200 force constitutes a quorum.
201 (6) STRIKE FORCE DUTIES.—The strike force shall provide
202 advice and make recommendations, as necessary, to the Chief
203 Financial Officer.
204 (a) The strike force may advise the Chief Financial Officer
205 on initiatives that include, but are not limited to:
206 1. Conducting a census of local, state, and federal efforts
207 to address Medicaid and public assistance fraud in this state,
208 including fraud detection, prevention, and prosecution, in order
209 to discern overlapping missions, maximize existing resources,
210 and strengthen current programs.
211 2. Developing a strategic plan for coordinating and
212 targeting state and local resources for preventing and
213 prosecuting Medicaid and public assistance fraud. The plan must
214 identify methods to enhance multiagency efforts that contribute
215 to achieving the state’s goal of eliminating Medicaid and public
216 assistance fraud.
217 3. Identifying methods to implement innovative technology
218 and data sharing in order to detect and analyze Medicaid and
219 public assistance fraud with speed and efficiency.
220 4. Establishing a program to provide grants to state and
221 local agencies that develop and implement effective Medicaid and
222 public assistance fraud prevention, detection, and investigation
223 programs, which are evaluated by the strike force and ranked by
224 their potential to contribute to achieving the state’s goal of
225 eliminating Medicaid and public assistance fraud. The grant
226 program may also provide startup funding for new initiatives by
227 local and state law enforcement or administrative agencies to
228 combat Medicaid and public assistance fraud.
229 5. Developing and promoting crime prevention services and
230 educational programs that serve the public, including, but not
231 limited to, a well-publicized rewards program for the
232 apprehension and conviction of criminals who perpetrate Medicaid
233 and public assistance fraud.
234 6. Providing grants, contingent upon appropriation, for
235 multiagency or state and local Medicaid and public assistance
236 fraud efforts, which include, but are not limited to:
237 a. Providing for a Medicaid and public assistance fraud
238 prosecutor in the Office of the Statewide Prosecutor.
239 b. Providing assistance to state attorneys for support
240 services or equipment, or for the hiring of assistant state
241 attorneys, as needed, to prosecute Medicaid and public
242 assistance fraud cases.
243 c. Providing assistance to judges for support services or
244 for the hiring of senior judges, as needed, so that Medicaid and
245 public assistance fraud cases can be heard expeditiously.
246 (b) The strike force shall receive periodic reports from
247 state agencies, law enforcement officers, investigators,
248 prosecutors, and coordinating teams regarding Medicaid and
249 public assistance criminal and civil investigations. Such
250 reports may include discussions regarding significant factors
251 and trends relevant to a statewide Medicaid and public
252 assistance fraud strategy.
253 (7) REPORTS.—The strike force shall annually prepare and
254 submit a report on its activities and recommendations, by
255 October 1, to the President of the Senate, the Speaker of the
256 House of Representatives, the Governor, and the chairs of the
257 House of Representatives and Senate committees that have
258 substantive jurisdiction over Medicaid and public assistance
259 fraud.
260 Section 5. Section 624.352, Florida Statutes, is created to
261 read:
262 624.352 Interagency agreements to detect and deter Medicaid
263 and public assistance fraud.—
264 (1) The Chief Financial Officer shall prepare model
265 interagency agreements for the coordination of prevention,
266 investigation, and prosecution of Medicaid and public assistance
267 fraud to be known as “Strike Force” agreements. Parties to such
268 agreements may include any agency that is headed by a Cabinet
269 officer, the Governor, the Governor and Cabinet, a collegial
270 body, or any federal, state, or local law enforcement agency.
271 (2) The agreements must include, but are not limited to:
272 (a) Establishing the agreement’s purpose, mission,
273 authority, organizational structure, procedures, supervision,
274 operations, deputations, funding, expenditures, property and
275 equipment, reports and records, assets and forfeitures, media
276 policy, liability, and duration.
277 (b) Requiring that parties to an agreement have appropriate
278 powers and authority relative to the purpose and mission of the
279 agreement.
280 Section 6. Section 16.59, Florida Statutes, is amended to
281 read:
282 16.59 Medicaid fraud control.—The Medicaid Fraud Control
283 Unit There is created in the Department of Legal Affairs to the
284 Medicaid Fraud Control Unit, which may investigate all
285 violations of s. 409.920 and any criminal violations discovered
286 during the course of those investigations. The Medicaid Fraud
287 Control Unit may refer any criminal violation so uncovered to
288 the appropriate prosecuting authority. The offices of the
289 Medicaid Fraud Control Unit, and the offices of the Agency for
290 Health Care Administration Medicaid program integrity program,
291 and the Divisions of Insurance Fraud and Public Assistance Fraud
292 within the Department of Financial Services shall, to the extent
293 possible, be collocated; however, positions dedicated to
294 Medicaid managed care fraud within the Medicaid Fraud Control
295 Unit shall be collocated with the Division of Insurance Fraud.
296 The Agency for Health Care Administration, and the Department of
297 Legal Affairs, and the Divisions of Insurance Fraud and Public
298 Assistance Fraud within the Department of Financial Services
299 shall conduct joint training and other joint activities designed
300 to increase communication and coordination in recovering
301 overpayments.
302 Section 7. Paragraph (o) is added to subsection (2) of
303 section 20.121, Florida Statutes, to read:
304 20.121 Department of Financial Services.—There is created a
305 Department of Financial Services.
306 (2) DIVISIONS.—The Department of Financial Services shall
307 consist of the following divisions:
308 (o) The Division of Public Assistance Fraud.
309 Section 8. Paragraph (b) of subsection (7) of section
310 411.01, Florida Statutes, is amended to read:
311 411.01 School readiness programs; early learning
312 coalitions.—
313 (7) PARENTAL CHOICE.—
314 (b) If it is determined that a provider has provided any
315 cash to the beneficiary in return for receiving the purchase
316 order, the early learning coalition or its fiscal agent shall
317 refer the matter to the Department of Financial Services
318 pursuant to s. 414.411 Division of Public Assistance Fraud for
319 investigation.
320 Section 9. Subsection (2) of section 414.33, Florida
321 Statutes, is amended to read:
322 414.33 Violations of food stamp program.—
323 (2) In addition, the department shall establish procedures
324 for referring to the Department of Law Enforcement any case that
325 involves a suspected violation of federal or state law or rules
326 governing the administration of the food stamp program to the
327 Department of Financial Services pursuant to s. 414.411.
328 Section 10. Subsection (9) of section 414.39, Florida
329 Statutes, is amended to read:
330 414.39 Fraud.—
331 (9) All records relating to investigations of public
332 assistance fraud in the custody of the department and the Agency
333 for Health Care Administration are available for examination by
334 the Department of Financial Services Law Enforcement pursuant to
335 s. 414.411 943.401 and are admissible into evidence in
336 proceedings brought under this section as business records
337 within the meaning of s. 90.803(6).
338 Section 11. Section 943.401, Florida Statutes, is
339 transferred, renumbered as section 414.411, Florida Statutes,
340 and amended to read:
341 414.411 943.401 Public assistance fraud.—
342 (1)(a) The Department of Financial Services Law Enforcement
343 shall investigate all public assistance provided to residents of
344 the state or provided to others by the state. In the course of
345 such investigation the department of Law Enforcement shall
346 examine all records, including electronic benefits transfer
347 records and make inquiry of all persons who may have knowledge
348 as to any irregularity incidental to the disbursement of public
349 moneys, food stamps, or other items or benefits authorizations
350 to recipients.
351 (b) All public assistance recipients, as a condition
352 precedent to qualification for public assistance received and as
353 defined under the provisions of chapter 409, chapter 411, or
354 this chapter 414, must shall first give in writing, to the
355 Agency for Health Care Administration, the Department of Health,
356 the Agency for Workforce Innovation, and the Department of
357 Children and Family Services, as appropriate, and to the
358 Department of Financial Services Law Enforcement, consent to
359 make inquiry of past or present employers and records, financial
360 or otherwise.
361 (2) In the conduct of such investigation the Department of
362 Financial Services Law Enforcement may employ persons having
363 such qualifications as are useful in the performance of this
364 duty.
365 (3) The results of such investigation shall be reported by
366 the Department of Financial Services Law Enforcement to the
367 appropriate legislative committees, the Agency for Health Care
368 Administration, the Department of Health, the Agency for
369 Workforce Innovation, and the Department of Children and Family
370 Services, and to such others as the department of Law
371 Enforcement may determine.
372 (4) The Department of Health and the Department of Children
373 and Family Services shall report to the Department of Financial
374 Services Law Enforcement the final disposition of all cases
375 wherein action has been taken pursuant to s. 414.39, based upon
376 information furnished by the Department of Financial Services
377 Law Enforcement.
378 (5) All lawful fees and expenses of officers and witnesses,
379 expenses incident to taking testimony and transcripts of
380 testimony and proceedings are a proper charge to the Department
381 of Financial Services Law Enforcement.
382 (6) The provisions of this section shall be liberally
383 construed in order to carry out effectively the purposes of this
384 section in the interest of protecting public moneys and other
385 public property.
386 Section 12. Section 409.91212, Florida Statutes, is created
387 to read:
388 409.91212 Medicaid managed care fraud.—
389 (1) Each managed care plan, as defined in s. 409.920(1)(e),
390 shall adopt an anti-fraud plan addressing the detection and
391 prevention of overpayments, abuse, and fraud relating to the
392 provision of and payment for Medicaid services and submit the
393 plan to the Office of Medicaid Program Integrity within the
394 agency for approval. At a minimum, the anti-fraud plan must
395 include:
396 (a) A written description or chart outlining the
397 organizational arrangement of the plan’s personnel who are
398 responsible for the investigation and reporting of possible
399 overpayment, abuse, or fraud;
400 (b) A description of the plan’s procedures for detecting
401 and investigating possible acts of fraud, abuse, and
402 overpayment;
403 (c) A description of the plan’s procedures for the
404 mandatory reporting of possible overpayment, abuse, or fraud to
405 the Office of Medicaid Program Integrity within the agency;
406 (d) A description of the plan’s program and procedures for
407 educating and training personnel on how to detect and prevent
408 fraud, abuse, and overpayment;
409 (e) The name, address, telephone number, e-mail address,
410 and fax number of the individual responsible for carrying out
411 the anti-fraud plan; and
412 (f) A summary of the results of the investigations of
413 fraud, abuse, or overpayment which were conducted during the
414 previous year by the managed care organization’s fraud
415 investigative unit.
416 (2) A managed care plan that provides Medicaid services
417 shall:
418 (a) Establish and maintain a fraud investigative unit to
419 investigate possible acts of fraud, abuse, and overpayment; or
420 (b) Contract for the investigation of possible fraudulent
421 or abusive acts by Medicaid recipients, persons providing
422 services to Medicaid recipients, or any other persons.
423 (3) If a managed care plan contracts for the investigation
424 of fraudulent claims and other types of program abuse by
425 recipients or service providers, the managed care plan shall
426 file the following with the Office of Medicaid Program Integrity
427 within the agency for approval before the plan executes any
428 contracts for fraud and abuse prevention and detection:
429 (a) A copy of the written contract between the plan and the
430 contracting entity;
431 (b) The names, addresses, telephone numbers, e-mail
432 addresses, and fax numbers of the principals of the entity with
433 which the managed care plan has contracted; and
434 (c) A description of the qualifications of the principals
435 of the entity with which the managed care plan has contracted.
436 (4) On or before September 1 of each year, each managed
437 care plan shall report to the Office of Medicaid Program
438 Integrity within the agency on its experience in implementing an
439 anti-fraud plan, as provided under subsection (1), and, if
440 applicable, conducting or contracting for investigations of
441 possible fraudulent or abusive acts as provided under this
442 section for the prior state fiscal year. The report must
443 include, at a minimum:
444 (a) The dollar amount of losses and recoveries attributable
445 to overpayment, abuse, and fraud.
446 (b) The number of referrals to the Office of Medicaid
447 Program Integrity during the prior year.
448 (5) If a managed care plan fails to timely submit a final
449 acceptable anti-fraud plan, fails to timely submit its annual
450 report, fails to implement its anti-fraud plan or investigative
451 unit, if applicable, or otherwise refuses to comply with this
452 section, the agency shall impose:
453 (a) An administrative fine of $2,000 per calendar day for
454 failure to submit an acceptable anti-fraud plan or report until
455 the agency deems the managed care plan or report to be in
456 compliance;
457 (b) An administrative fine of not more than $10,000 for
458 failure by a managed care plan to implement an anti-fraud plan
459 or investigative unit, as applicable; or
460 (c) The administrative fines pursuant to paragraphs (a) and
461 (b).
462 (6) Each managed care plan shall report all suspected or
463 confirmed instances of provider or recipient fraud or abuse
464 within 15 calendar days after detection to the Office of
465 Medicaid Program Integrity within the agency. At a minimum the
466 report must contain the name of the provider or recipient, the
467 Medicaid billing number or tax identification number, and a
468 description of the fraudulent or abusive act. The Office of
469 Medicaid Program Integrity in the agency shall forward the
470 report of suspected overpayment, abuse, or fraud to the
471 appropriate investigative unit, including, but not limited to,
472 the Bureau of Medicaid program integrity, the Medicaid fraud
473 control unit, the Division of Public Assistance Fraud, the
474 Division of Insurance Fraud, or the Department of Law
475 Enforcement.
476 (a) Failure to timely report shall result in an
477 administrative fine of $1,000 per calendar day after the 15th
478 day of detection.
479 (b) Failure to timely report may result in additional
480 administrative, civil, or criminal penalties.
481 (7) The agency may adopt rules to administer this section.
482 Section 13. Review of the Medicaid fraud and abuse
483 processes.—
484 (1) The Auditor General and the Office of Program Policy
485 Analysis and Government Accountability shall review and evaluate
486 the Agency for Health Care Administration’s Medicaid fraud and
487 abuse systems, including the Medicaid program integrity program.
488 The reviewers may access Medicaid-related information and data
489 from the Attorney General’s Medicaid Fraud Control Unit, the
490 Department of Health, the Department of Elderly Affairs, the
491 Agency for Persons with Disabilities, and the Department of
492 Children and Family Services, as necessary, to conduct the
493 review. The review must include, but is not limited to:
494 (a) An evaluation of current Medicaid policies and the
495 Medicaid fiscal agent;
496 (b) An analysis of the Medicaid fraud and abuse prevention
497 and detection processes, including agency contracts, Medicaid
498 databases, and internal control risk assessments;
499 (c) A comprehensive evaluation of the effectiveness of the
500 current laws, rules, and contractual requirements that govern
501 Medicaid managed care entities;
502 (d) An evaluation of the agency’s Medicaid managed care
503 oversight processes;
504 (e) Recommendations to improve the Medicaid claims
505 adjudication process, to increase the overall efficiency of the
506 Medicaid program, and to reduce Medicaid overpayments; and
507 (f) Operational and legislative recommendations to improve
508 the prevention and detection of fraud and abuse in the Medicaid
509 managed care program.
510 (2) The Auditor General’s Office and the Office of Program
511 Policy Analysis and Government Accountability may contract with
512 technical consultants to assist in the performance of the
513 review. The Auditor General and the Office of Program Policy
514 Analysis and Government Accountability shall report to the
515 President of the Senate, the Speaker of the House of
516 Representatives, and the Governor by December 1, 2011.
517 Section 14. Medicaid claims adjudication project.—The
518 Agency for Health Care Administration shall issue a competitive
519 procurement pursuant to chapter 287, Florida Statutes, with a
520 third-party vendor, at no cost to the state, to provide a real
521 time, front-end database to augment the Medicaid fiscal agent
522 program edits and claims adjudication process. The vendor shall
523 provide an interface with the Medicaid fiscal agent to decrease
524 inaccurate payment to Medicaid providers and improve the overall
525 efficiency of the Medicaid claims-processing system.
526 Section 15. Effective July 1, 2010, paragraph (b) of
527 subsection (4) of section 409.912, Florida Statutes, is amended,
528 and paragraph (d) of that subsection is republished, to read:
529 409.912 Cost-effective purchasing of health care.—The
530 agency shall purchase goods and services for Medicaid recipients
531 in the most cost-effective manner consistent with the delivery
532 of quality medical care. To ensure that medical services are
533 effectively utilized, the agency may, in any case, require a
534 confirmation or second physician’s opinion of the correct
535 diagnosis for purposes of authorizing future services under the
536 Medicaid program. This section does not restrict access to
537 emergency services or poststabilization care services as defined
538 in 42 C.F.R. part 438.114. Such confirmation or second opinion
539 shall be rendered in a manner approved by the agency. The agency
540 shall maximize the use of prepaid per capita and prepaid
541 aggregate fixed-sum basis services when appropriate and other
542 alternative service delivery and reimbursement methodologies,
543 including competitive bidding pursuant to s. 287.057, designed
544 to facilitate the cost-effective purchase of a case-managed
545 continuum of care. The agency shall also require providers to
546 minimize the exposure of recipients to the need for acute
547 inpatient, custodial, and other institutional care and the
548 inappropriate or unnecessary use of high-cost services. The
549 agency shall contract with a vendor to monitor and evaluate the
550 clinical practice patterns of providers in order to identify
551 trends that are outside the normal practice patterns of a
552 provider’s professional peers or the national guidelines of a
553 provider’s professional association. The vendor must be able to
554 provide information and counseling to a provider whose practice
555 patterns are outside the norms, in consultation with the agency,
556 to improve patient care and reduce inappropriate utilization.
557 The agency may mandate prior authorization, drug therapy
558 management, or disease management participation for certain
559 populations of Medicaid beneficiaries, certain drug classes, or
560 particular drugs to prevent fraud, abuse, overuse, and possible
561 dangerous drug interactions. The Pharmaceutical and Therapeutics
562 Committee shall make recommendations to the agency on drugs for
563 which prior authorization is required. The agency shall inform
564 the Pharmaceutical and Therapeutics Committee of its decisions
565 regarding drugs subject to prior authorization. The agency is
566 authorized to limit the entities it contracts with or enrolls as
567 Medicaid providers by developing a provider network through
568 provider credentialing. The agency may competitively bid single
569 source-provider contracts if procurement of goods or services
570 results in demonstrated cost savings to the state without
571 limiting access to care. The agency may limit its network based
572 on the assessment of beneficiary access to care, provider
573 availability, provider quality standards, time and distance
574 standards for access to care, the cultural competence of the
575 provider network, demographic characteristics of Medicaid
576 beneficiaries, practice and provider-to-beneficiary standards,
577 appointment wait times, beneficiary use of services, provider
578 turnover, provider profiling, provider licensure history,
579 previous program integrity investigations and findings, peer
580 review, provider Medicaid policy and billing compliance records,
581 clinical and medical record audits, and other factors. Providers
582 shall not be entitled to enrollment in the Medicaid provider
583 network. The agency shall determine instances in which allowing
584 Medicaid beneficiaries to purchase durable medical equipment and
585 other goods is less expensive to the Medicaid program than long
586 term rental of the equipment or goods. The agency may establish
587 rules to facilitate purchases in lieu of long-term rentals in
588 order to protect against fraud and abuse in the Medicaid program
589 as defined in s. 409.913. The agency may seek federal waivers
590 necessary to administer these policies.
591 (4) The agency may contract with:
592 (b) An entity that is providing comprehensive behavioral
593 health care services to certain Medicaid recipients through a
594 capitated, prepaid arrangement pursuant to the federal waiver
595 provided for by s. 409.905(5). Such entity must be licensed
596 under chapter 624, chapter 636, or chapter 641, or authorized
597 under paragraph (c) or paragraph (d), and must possess the
598 clinical systems and operational competence to manage risk and
599 provide comprehensive behavioral health care to Medicaid
600 recipients. As used in this paragraph, the term “comprehensive
601 behavioral health care services” means covered mental health and
602 substance abuse treatment services that are available to
603 Medicaid recipients. The secretary of the Department of Children
604 and Family Services shall approve provisions of procurements
605 related to children in the department’s care or custody before
606 enrolling such children in a prepaid behavioral health plan. Any
607 contract awarded under this paragraph must be competitively
608 procured. In developing the behavioral health care prepaid plan
609 procurement document, the agency shall ensure that the
610 procurement document requires the contractor to develop and
611 implement a plan to ensure compliance with s. 394.4574 related
612 to services provided to residents of licensed assisted living
613 facilities that hold a limited mental health license. Except as
614 provided in subparagraph 8., and except in counties where the
615 Medicaid managed care pilot program is authorized pursuant to s.
616 409.91211, the agency shall seek federal approval to contract
617 with a single entity meeting these requirements to provide
618 comprehensive behavioral health care services to all Medicaid
619 recipients not enrolled in a Medicaid managed care plan
620 authorized under s. 409.91211, a provider service network
621 authorized under paragraph (d), or a Medicaid health maintenance
622 organization in an AHCA area. In an AHCA area where the Medicaid
623 managed care pilot program is authorized pursuant to s.
624 409.91211 in one or more counties, the agency may procure a
625 contract with a single entity to serve the remaining counties as
626 an AHCA area or the remaining counties may be included with an
627 adjacent AHCA area and are subject to this paragraph. Each
628 entity must offer a sufficient choice of providers in its
629 network to ensure recipient access to care and the opportunity
630 to select a provider with whom they are satisfied. The network
631 shall include all public mental health hospitals. To ensure
632 unimpaired access to behavioral health care services by Medicaid
633 recipients, all contracts issued pursuant to this paragraph must
634 require 80 percent of the capitation paid to the managed care
635 plan, including health maintenance organizations and capitated
636 provider service networks, to be expended for the provision of
637 behavioral health care services. If the managed care plan
638 expends less than 80 percent of the capitation paid for the
639 provision of behavioral health care services, the difference
640 shall be returned to the agency. The agency shall provide the
641 plan with a certification letter indicating the amount of
642 capitation paid during each calendar year for behavioral health
643 care services pursuant to this section. The agency may reimburse
644 for substance abuse treatment services on a fee-for-service
645 basis until the agency finds that adequate funds are available
646 for capitated, prepaid arrangements.
647 1. By January 1, 2001, the agency shall modify the
648 contracts with the entities providing comprehensive inpatient
649 and outpatient mental health care services to Medicaid
650 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
651 Counties, to include substance abuse treatment services.
652 2. By July 1, 2003, the agency and the Department of
653 Children and Family Services shall execute a written agreement
654 that requires collaboration and joint development of all policy,
655 budgets, procurement documents, contracts, and monitoring plans
656 that have an impact on the state and Medicaid community mental
657 health and targeted case management programs.
658 3. Except as provided in subparagraph 8., by July 1, 2006,
659 the agency and the Department of Children and Family Services
660 shall contract with managed care entities in each AHCA area
661 except area 6 or arrange to provide comprehensive inpatient and
662 outpatient mental health and substance abuse services through
663 capitated prepaid arrangements to all Medicaid recipients who
664 are eligible to participate in such plans under federal law and
665 regulation. In AHCA areas where eligible individuals number less
666 than 150,000, the agency shall contract with a single managed
667 care plan to provide comprehensive behavioral health services to
668 all recipients who are not enrolled in a Medicaid health
669 maintenance organization, a provider service network authorized
670 under paragraph (d), or a Medicaid capitated managed care plan
671 authorized under s. 409.91211. The agency may contract with more
672 than one comprehensive behavioral health provider to provide
673 care to recipients who are not enrolled in a Medicaid capitated
674 managed care plan authorized under s. 409.91211, a provider
675 service network authorized under paragraph (d), or a Medicaid
676 health maintenance organization in AHCA areas where the eligible
677 population exceeds 150,000. In an AHCA area where the Medicaid
678 managed care pilot program is authorized pursuant to s.
679 409.91211 in one or more counties, the agency may procure a
680 contract with a single entity to serve the remaining counties as
681 an AHCA area or the remaining counties may be included with an
682 adjacent AHCA area and shall be subject to this paragraph.
683 Contracts for comprehensive behavioral health providers awarded
684 pursuant to this section shall be competitively procured. Both
685 for-profit and not-for-profit corporations are eligible to
686 compete. Managed care plans contracting with the agency under
687 subsection (3) or paragraph (d), shall provide and receive
688 payment for the same comprehensive behavioral health benefits as
689 provided in AHCA rules, including handbooks incorporated by
690 reference. In AHCA area 11, the agency shall contract with at
691 least two comprehensive behavioral health care providers to
692 provide behavioral health care to recipients in that area who
693 are enrolled in, or assigned to, the MediPass program. One of
694 the behavioral health care contracts must be with the existing
695 provider service network pilot project, as described in
696 paragraph (d), for the purpose of demonstrating the cost
697 effectiveness of the provision of quality mental health services
698 through a public hospital-operated managed care model. Payment
699 shall be at an agreed-upon capitated rate to ensure cost
700 savings. Of the recipients in area 11 who are assigned to
701 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
702 MediPass-enrolled recipients shall be assigned to the existing
703 provider service network in area 11 for their behavioral care.
704 4. By October 1, 2003, the agency and the department shall
705 submit a plan to the Governor, the President of the Senate, and
706 the Speaker of the House of Representatives which provides for
707 the full implementation of capitated prepaid behavioral health
708 care in all areas of the state.
709 a. Implementation shall begin in 2003 in those AHCA areas
710 of the state where the agency is able to establish sufficient
711 capitation rates.
712 b. If the agency determines that the proposed capitation
713 rate in any area is insufficient to provide appropriate
714 services, the agency may adjust the capitation rate to ensure
715 that care will be available. The agency and the department may
716 use existing general revenue to address any additional required
717 match but may not over-obligate existing funds on an annualized
718 basis.
719 c. Subject to any limitations provided in the General
720 Appropriations Act, the agency, in compliance with appropriate
721 federal authorization, shall develop policies and procedures
722 that allow for certification of local and state funds.
723 5. Children residing in a statewide inpatient psychiatric
724 program, or in a Department of Juvenile Justice or a Department
725 of Children and Family Services residential program approved as
726 a Medicaid behavioral health overlay services provider may not
727 be included in a behavioral health care prepaid health plan or
728 any other Medicaid managed care plan pursuant to this paragraph.
729 6. In converting to a prepaid system of delivery, the
730 agency shall in its procurement document require an entity
731 providing only comprehensive behavioral health care services to
732 prevent the displacement of indigent care patients by enrollees
733 in the Medicaid prepaid health plan providing behavioral health
734 care services from facilities receiving state funding to provide
735 indigent behavioral health care, to facilities licensed under
736 chapter 395 which do not receive state funding for indigent
737 behavioral health care, or reimburse the unsubsidized facility
738 for the cost of behavioral health care provided to the displaced
739 indigent care patient.
740 7. Traditional community mental health providers under
741 contract with the Department of Children and Family Services
742 pursuant to part IV of chapter 394, child welfare providers
743 under contract with the Department of Children and Family
744 Services in areas 1 and 6, and inpatient mental health providers
745 licensed pursuant to chapter 395 must be offered an opportunity
746 to accept or decline a contract to participate in any provider
747 network for prepaid behavioral health services.
748 8. All Medicaid-eligible children, except children in area
749 1 and children in Highlands County, Hardee County, Polk County,
750 or Manatee County of area 6, that are open for child welfare
751 services in the HomeSafeNet system, shall receive their
752 behavioral health care services through a specialty prepaid plan
753 operated by community-based lead agencies through a single
754 agency or formal agreements among several agencies. The
755 specialty prepaid plan must result in savings to the state
756 comparable to savings achieved in other Medicaid managed care
757 and prepaid programs. Such plan must provide mechanisms to
758 maximize state and local revenues. The specialty prepaid plan
759 shall be developed by the agency and the Department of Children
760 and Family Services. The agency may seek federal waivers to
761 implement this initiative. Medicaid-eligible children whose
762 cases are open for child welfare services in the HomeSafeNet
763 system and who reside in AHCA area 10 are exempt from the
764 specialty prepaid plan upon the development of a service
765 delivery mechanism for children who reside in area 10 as
766 specified in s. 409.91211(3)(dd).
767 (d) A provider service network may be reimbursed on a fee
768 for-service or prepaid basis. A provider service network which
769 is reimbursed by the agency on a prepaid basis shall be exempt
770 from parts I and III of chapter 641, but must comply with the
771 solvency requirements in s. 641.2261(2) and meet appropriate
772 financial reserve, quality assurance, and patient rights
773 requirements as established by the agency. Medicaid recipients
774 assigned to a provider service network shall be chosen equally
775 from those who would otherwise have been assigned to prepaid
776 plans and MediPass. The agency is authorized to seek federal
777 Medicaid waivers as necessary to implement the provisions of
778 this section. Any contract previously awarded to a provider
779 service network operated by a hospital pursuant to this
780 subsection shall remain in effect for a period of 3 years
781 following the current contract expiration date, regardless of
782 any contractual provisions to the contrary. A provider service
783 network is a network established or organized and operated by a
784 health care provider, or group of affiliated health care
785 providers, including minority physician networks and emergency
786 room diversion programs that meet the requirements of s.
787 409.91211, which provides a substantial proportion of the health
788 care items and services under a contract directly through the
789 provider or affiliated group of providers and may make
790 arrangements with physicians or other health care professionals,
791 health care institutions, or any combination of such individuals
792 or institutions to assume all or part of the financial risk on a
793 prospective basis for the provision of basic health services by
794 the physicians, by other health professionals, or through the
795 institutions. The health care providers must have a controlling
796 interest in the governing body of the provider service network
797 organization.
798 Section 16. Effective July 1, 2010, paragraphs (e) and (dd)
799 of subsection (3) of section 409.91211, Florida Statutes, are
800 amended to read:
801 409.91211 Medicaid managed care pilot program.—
802 (3) The agency shall have the following powers, duties, and
803 responsibilities with respect to the pilot program:
804 (e) To implement policies and guidelines for phasing in
805 financial risk for approved provider service networks that, for
806 purposes of this paragraph, include the Children’s Medical
807 Services Network, over the a 5-year period of the waiver and the
808 extension thereof. These policies and guidelines must include an
809 option for a provider service network to be paid fee-for-service
810 rates. For any provider service network established in a managed
811 care pilot area, the option to be paid fee-for-service rates
812 must include a savings-settlement mechanism that is consistent
813 with s. 409.912(44). This model must be converted to a risk
814 adjusted capitated rate by the beginning of the final sixth year
815 of operation under the waiver extension, and may be converted
816 earlier at the option of the provider service network. Federally
817 qualified health centers may be offered an opportunity to accept
818 or decline a contract to participate in any provider network for
819 prepaid primary care services.
820 (dd) To implement service delivery mechanisms within a
821 specialty plan in area 10 capitated managed care plans to
822 provide behavioral health care services Medicaid services as
823 specified in ss. 409.905 and 409.906 to Medicaid-eligible
824 children whose cases are open for child welfare services in the
825 HomeSafeNet system. These services must be coordinated with
826 community-based care providers as specified in s. 409.1671,
827 where available, and be sufficient to meet the medical,
828 developmental, behavioral, and emotional needs of these
829 children. Children in area 10 who have an open case in the
830 HomeSafeNet system shall be enrolled into the specialty plan.
831 These service delivery mechanisms must be implemented no later
832 than July 1, 2011 2008, in AHCA area 10 in order for the
833 children in AHCA area 10 to remain exempt from the statewide
834 plan under s. 409.912(4)(b)8. An administrative fee may be paid
835 to the specialty plan for the coordination of services based on
836 the receipt of the state share of that fee being provided
837 through intergovernmental transfers.
838 Section 17. All powers, duties, functions, records,
839 offices, personnel, property, pending issues and existing
840 contracts, administrative authority, administrative rules, and
841 unexpended balances of appropriations, allocations, and other
842 funds relating to public assistance fraud in the Department of
843 Law Enforcement are transferred by a type two transfer, as
844 defined in s. 20.06(2), Florida Statutes, to the Division of
845 Public Assistance Fraud in the Department of Financial Services.
846 Section 18. Except as otherwise expressly provided in this
847 act and except for sections 1, 2, 12, 13, and 14 of this act and
848 this section, which shall take effect upon this act becoming a
849 law, this act shall take effect January 1, 2011.