HB 583

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 409.912, F.S.;
3	requiring that funds repaid to the Agency for Health Care
4	Administration by managed care plans that spend less than
5	a certain percentage of the capitation rate for behavioral
6	health services be deposited into the Medical Care Trust
7	Fund; providing that such repayments be allocated to
8	community behavioral health providers and used for
9	Medicaid behavioral and case management services;
10	providing an effective date.
11
12	Be It Enacted by the Legislature of the State of Florida:
13
14	Section 1.  Paragraph (b) of subsection (4) of section
15	409.912, Florida Statutes, is amended to read:
16	409.912  Cost-effective purchasing of health care.-The
17	agency shall purchase goods and services for Medicaid recipients
18	in the most cost-effective manner consistent with the delivery
19	of quality medical care. To ensure that medical services are
20	effectively utilized, the agency may, in any case, require a
21	confirmation or second physician's opinion of the correct
22	diagnosis for purposes of authorizing future services under the
23	Medicaid program. This section does not restrict access to
24	emergency services or poststabilization care services as defined
25	in 42 C.F.R. part 438.114. Such confirmation or second opinion
26	shall be rendered in a manner approved by the agency. The agency
27	shall maximize the use of prepaid per capita and prepaid
28	aggregate fixed-sum basis services when appropriate and other
29	alternative service delivery and reimbursement methodologies,
30	including competitive bidding pursuant to s. 287.057, designed
31	to facilitate the cost-effective purchase of a case-managed
32	continuum of care. The agency shall also require providers to
33	minimize the exposure of recipients to the need for acute
34	inpatient, custodial, and other institutional care and the
35	inappropriate or unnecessary use of high-cost services. The
36	agency shall contract with a vendor to monitor and evaluate the
37	clinical practice patterns of providers in order to identify
38	trends that are outside the normal practice patterns of a
39	provider's professional peers or the national guidelines of a
40	provider's professional association. The vendor must be able to
41	provide information and counseling to a provider whose practice
42	patterns are outside the norms, in consultation with the agency,
43	to improve patient care and reduce inappropriate utilization.
44	The agency may mandate prior authorization, drug therapy
45	management, or disease management participation for certain
46	populations of Medicaid beneficiaries, certain drug classes, or
47	particular drugs to prevent fraud, abuse, overuse, and possible
48	dangerous drug interactions. The Pharmaceutical and Therapeutics
49	Committee shall make recommendations to the agency on drugs for
50	which prior authorization is required. The agency shall inform
51	the Pharmaceutical and Therapeutics Committee of its decisions
52	regarding drugs subject to prior authorization. The agency is
53	authorized to limit the entities it contracts with or enrolls as
54	Medicaid providers by developing a provider network through
55	provider credentialing. The agency may competitively bid single-
56	source-provider contracts if procurement of goods or services
57	results in demonstrated cost savings to the state without
58	limiting access to care. The agency may limit its network based
59	on the assessment of beneficiary access to care, provider
60	availability, provider quality standards, time and distance
61	standards for access to care, the cultural competence of the
62	provider network, demographic characteristics of Medicaid
63	beneficiaries, practice and provider-to-beneficiary standards,
64	appointment wait times, beneficiary use of services, provider
65	turnover, provider profiling, provider licensure history,
66	previous program integrity investigations and findings, peer
67	review, provider Medicaid policy and billing compliance records,
68	clinical and medical record audits, and other factors. Providers
69	shall not be entitled to enrollment in the Medicaid provider
70	network. The agency shall determine instances in which allowing
71	Medicaid beneficiaries to purchase durable medical equipment and
72	other goods is less expensive to the Medicaid program than long-
73	term rental of the equipment or goods. The agency may establish
74	rules to facilitate purchases in lieu of long-term rentals in
75	order to protect against fraud and abuse in the Medicaid program
76	as defined in s. 409.913. The agency may seek federal waivers
77	necessary to administer these policies.
78	(4)  The agency may contract with:
79	(b)  An entity that is providing comprehensive behavioral
80	health care services to certain Medicaid recipients through a
81	capitated, prepaid arrangement pursuant to the federal waiver
82	authorized in provided for by s. 409.905(5). Such entity must be
83	licensed under chapter 624, chapter 636, or chapter 641, or
84	authorized under paragraph (c), and must possess the clinical
85	systems and operational competence to manage risk and provide
86	comprehensive behavioral health care to Medicaid recipients. As
87	used in this paragraph, the term "comprehensive behavioral
88	health care services" means covered mental health and substance
89	abuse treatment services that are available to Medicaid
90	recipients. The Secretary of the Department of Children and
91	Family Services must shall approve provisions of procurements
92	related to children in the department's care or custody before
93	enrolling such children in a prepaid behavioral health plan. Any
94	contract awarded under this paragraph must be competitively
95	procured. In developing the behavioral health care prepaid plan
96	procurement document, the agency shall ensure that the
97	procurement document requires the contractor to develop and
98	implement a plan that ensures to ensure compliance with s.
99	394.4574 related to services provided to residents of licensed
100	assisted living facilities that hold a limited mental health
101	license. Except as provided in subparagraph 8., and except in
102	counties where the Medicaid managed care pilot program is
103	authorized pursuant to s. 409.91211, the agency shall seek
104	federal approval to contract with a single entity meeting these
105	requirements to provide comprehensive behavioral health care
106	services to all Medicaid recipients not enrolled in a Medicaid
107	managed care plan authorized under s. 409.91211 or a Medicaid
108	health maintenance organization in an AHCA area. In an AHCA area
109	where the Medicaid managed care pilot program is authorized
110	pursuant to s. 409.91211 in one or more counties, the agency may
111	procure a contract with a single entity to serve the remaining
112	counties as an AHCA area or the remaining counties may be
113	included with an adjacent AHCA area and are subject to this
114	paragraph. Each entity must offer a sufficient choice of
115	providers in its network to ensure recipient access to care and
116	the opportunity to select a provider with whom they are
117	satisfied. The network must shall include all public mental
118	health hospitals. To ensure unimpaired access to behavioral
119	health care services by Medicaid recipients, all contracts
120	issued pursuant to this paragraph must require 80 percent of the
121	capitation paid to the managed care plan, including health
122	maintenance organizations, to be expended for the provision of
123	behavioral health care services. If the managed care plan
124	expends less than 80 percent of the capitation paid for the
125	provision of behavioral health care services, the difference
126	shall be returned to the agency. The agency shall provide the
127	plan with a certification letter indicating the amount of
128	capitation paid during each calendar year for behavioral health
129	care services pursuant to this section. The agency may reimburse
130	for substance abuse treatment services on a fee-for-service
131	basis until the agency finds that adequate funds are available
132	for capitated, prepaid arrangements.
133	1.  By January 1, 2001, the agency shall modify the
134	contracts with the entities providing comprehensive inpatient
135	and outpatient mental health care services to Medicaid
136	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
137	Counties, to include substance abuse treatment services.
138	2.  By July 1, 2003, the agency and the department of
139	Children and Family Services shall execute a written agreement
140	that requires collaboration and joint development of all policy,
141	budgets, procurement documents, contracts, and monitoring plans
142	that have an impact on the state and Medicaid community mental
143	health and targeted case management programs.
144	3.  Except as provided in subparagraph 8., by July 1, 2006,
145	the agency and the department of Children and Family Services
146	shall contract with managed care entities in each AHCA area
147	except area 6 or arrange to provide comprehensive inpatient and
148	outpatient mental health and substance abuse services through
149	capitated prepaid arrangements to all Medicaid recipients who
150	are eligible to participate in such plans under federal law and
151	regulation. In AHCA areas where eligible individuals number
152	fewer less than 150,000, the agency shall contract with a single
153	managed care plan to provide comprehensive behavioral health
154	services to all recipients who are not enrolled in a Medicaid
155	health maintenance organization or a Medicaid capitated managed
156	care plan authorized under s. 409.91211. The agency may contract
157	with more than one comprehensive behavioral health provider to
158	provide care to recipients who are not enrolled in a Medicaid
159	capitated managed care plan authorized under s. 409.91211 or a
160	Medicaid health maintenance organization in AHCA areas where the
161	eligible population exceeds 150,000. In an AHCA area where the
162	Medicaid managed care pilot program is authorized pursuant to s.
163	409.91211 in one or more counties, the agency may procure a
164	contract with a single entity to serve the remaining counties as
165	an AHCA area or the remaining counties may be included with an
166	adjacent AHCA area and are shall be subject to this paragraph.
167	Contracts for comprehensive behavioral health providers awarded
168	pursuant to this section must shall be competitively procured.
169	Both for-profit and not-for-profit corporations are eligible to
170	compete. Managed care plans contracting with the agency under
171	subsection (3) must shall provide and receive payment for the
172	same comprehensive behavioral health benefits as provided in
173	AHCA rules, including handbooks incorporated by reference. In
174	AHCA area 11, the agency shall contract with at least two
175	comprehensive behavioral health care providers to provide
176	behavioral health care to recipients in that area who are
177	enrolled in, or assigned to, the MediPass program. One of the
178	behavioral health care contracts must be with the existing
179	provider service network pilot project, as described in
180	paragraph (d), for the purpose of demonstrating the cost-
181	effectiveness of providing the provision of quality mental
182	health services through a public hospital-operated managed care
183	model. Payment shall be at an agreed-upon capitated rate to
184	ensure cost savings. Of the recipients in area 11 who are
185	assigned to MediPass under s. 409.9122(2)(k), a minimum of
186	50,000 of those MediPass-enrolled recipients shall be assigned
187	to the existing provider service network in area 11 for their
188	behavioral care.
189	4.  By October 1, 2003, the agency and the department shall
190	submit a plan to the Governor, the President of the Senate, and
191	the Speaker of the House of Representatives which provides for
192	the full implementation of capitated prepaid behavioral health
193	care in all areas of the state.
194	a.  Implementation shall begin in 2003 in those AHCA areas
195	of the state where the agency is able to establish sufficient
196	capitation rates.
197	b.  If the agency determines that the proposed capitation
198	rate in any area is insufficient to provide appropriate
199	services, the agency may adjust the capitation rate to ensure
200	that care is will be available. The agency and the department
201	may use existing general revenue to address any additional
202	required match but may not over-obligate existing funds on an
203	annualized basis.
204	c.  Subject to any limitations provided in the General
205	Appropriations Act, the agency, in compliance with appropriate
206	federal authorization, shall develop policies and procedures
207	that allow for certification of local and state funds.
208	5.  Children residing in a statewide inpatient psychiatric
209	program, or in a Department of Juvenile Justice or a Department
210	of Children and Family Services residential program approved as
211	a Medicaid behavioral health overlay services provider may not
212	be included in a behavioral health care prepaid health plan or
213	any other Medicaid managed care plan pursuant to this paragraph.
214	6.  In converting to a prepaid system of delivery, the
215	agency shall in its procurement document require an entity
216	providing only comprehensive behavioral health care services to
217	prevent the displacement of indigent care patients by enrollees
218	in the Medicaid prepaid health plan providing behavioral health
219	care services from facilities receiving state funding to provide
220	indigent behavioral health care, to facilities licensed under
221	chapter 395 which do not receive state funding for indigent
222	behavioral health care, or reimburse the unsubsidized facility
223	for the cost of behavioral health care provided to the displaced
224	indigent care patient.
225	7.  Traditional community mental health providers under
226	contract with the department of Children and Family Services
227	pursuant to part IV of chapter 394, child welfare providers
228	under contract with the department of Children and Family
229	Services in areas 1 and 6, and inpatient mental health providers
230	licensed pursuant to chapter 395 must be offered an opportunity
231	to accept or decline a contract to participate in any provider
232	network for prepaid behavioral health services.
233	8.  All Medicaid-eligible children, except children in area
234	1 and children in Highlands County, Hardee County, Polk County,
235	or Manatee County of area 6, that are open for child welfare
236	services in the HomeSafeNet system, shall receive their
237	behavioral health care services through a specialty prepaid plan
238	operated by community-based lead agencies through a single
239	agency or formal agreements among several agencies. The
240	specialty prepaid plan must result in savings to the state
241	comparable to savings achieved in other Medicaid managed care
242	and prepaid programs. Such plan must provide mechanisms to
243	maximize state and local revenues. The specialty prepaid plan
244	shall be developed by the agency and the department of Children
245	and Family Services. The agency may seek federal waivers to
246	implement this initiative. Medicaid-eligible children whose
247	cases are open for child welfare services in the HomeSafeNet
248	system and who reside in AHCA area 10 are exempt from the
249	specialty prepaid plan upon the development of a service
250	delivery mechanism for children who reside in area 10 as
251	specified in s. 409.91211(3)(dd).
252	9.  To ensure unimpaired access to behavioral health care
253	services by Medicaid recipients, all contracts issued pursuant
254	to this paragraph must require that 80 percent of the capitation
255	paid to the managed care plan, including health maintenance
256	organizations, be expended for the provision of behavioral
257	health care services. If the plan expends less than 80 percent,
258	the difference must be returned to the agency and deposited into
259	the Medical Care Trust Fund. The agency shall maintain a
260	separate accounting of repayments deposited into the trust fund.
261	Repayments, minus federal matching funds that must be returned
262	to the Federal Government, shall be allocated to community
263	behavioral health providers enrolled in the networks of the
264	managed care plans that made the repayments. Funds shall be
265	allocated in proportion to each community behavioral health
266	agency's earnings from the managed care plan making the
267	repayment. Providers shall use the funds for any Medicaid-
268	allowable type of community behavioral health and case
269	management service. Community behavioral health agencies shall
270	be reimbursed by the agency on a fee-for-service basis for
271	allowable services up to their redistribution amount as
272	determined by the agency. Reinvestment amounts must be
273	calculated annually within 60 days after the managed care plan
274	files its annual 80 percent spending report.
275	Section 2.  This act shall take effect July 1, 2010.

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