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A bill to be entitled

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An act relating to Medicaid managed care plans; amending

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s. 409.912, F.S.; requiring an entity that contracts with

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the Agency for Health Care Administration to provide

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certain health care services to continue to offer

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previously authorized services while prior authorization

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is processed, pay certain claims, and develop and maintain

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an informal grievance system; defining the term "clean

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claim"; requiring the Agency for Health Care

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Administration to establish a formal grievance process;

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providing an effective date.

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

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     Section 1.  Paragraph (b) of subsection (4) of section

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409.912, Florida Statutes, is amended to read:

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

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agency shall purchase goods and services for Medicaid recipients

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in the most cost-effective manner consistent with the delivery of

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quality medical care. To ensure that medical services are

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effectively utilized, the agency may, in any case, require a

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confirmation or second physician's opinion of the correct

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diagnosis for purposes of authorizing future services under the

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Medicaid program. This section does not restrict access to

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emergency services or poststabilization care services as defined

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in 42 C.F.R. part 438.114. Such confirmation or second opinion

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shall be rendered in a manner approved by the agency. The agency

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shall maximize the use of prepaid per capita and prepaid

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aggregate fixed-sum basis services when appropriate and other

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alternative service delivery and reimbursement methodologies,

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including competitive bidding pursuant to s. 287.057, designed to

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facilitate the cost-effective purchase of a case-managed

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continuum of care. The agency shall also require providers to

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minimize the exposure of recipients to the need for acute

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inpatient, custodial, and other institutional care and the

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inappropriate or unnecessary use of high-cost services. The

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agency shall contract with a vendor to monitor and evaluate the

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clinical practice patterns of providers in order to identify

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trends that are outside the normal practice patterns of a

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provider's professional peers or the national guidelines of a

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provider's professional association. The vendor must be able to

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provide information and counseling to a provider whose practice

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patterns are outside the norms, in consultation with the agency,

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to improve patient care and reduce inappropriate utilization. The

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agency may mandate prior authorization, drug therapy management,

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or disease management participation for certain populations of

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Medicaid beneficiaries, certain drug classes, or particular drugs

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to prevent fraud, abuse, overuse, and possible dangerous drug

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interactions. The Pharmaceutical and Therapeutics Committee shall

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make recommendations to the agency on drugs for which prior

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authorization is required. The agency shall inform the

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Pharmaceutical and Therapeutics Committee of its decisions

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regarding drugs subject to prior authorization. The agency is

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authorized to limit the entities it contracts with or enrolls as

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Medicaid providers by developing a provider network through

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provider credentialing. The agency may competitively bid single-

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source-provider contracts if procurement of goods or services

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results in demonstrated cost savings to the state without

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limiting access to care. The agency may limit its network based

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on the assessment of beneficiary access to care, provider

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availability, provider quality standards, time and distance

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standards for access to care, the cultural competence of the

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provider network, demographic characteristics of Medicaid

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beneficiaries, practice and provider-to-beneficiary standards,

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appointment wait times, beneficiary use of services, provider

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turnover, provider profiling, provider licensure history,

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previous program integrity investigations and findings, peer

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review, provider Medicaid policy and billing compliance records,

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clinical and medical record audits, and other factors. Providers

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shall not be entitled to enrollment in the Medicaid provider

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network. The agency shall determine instances in which allowing

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Medicaid beneficiaries to purchase durable medical equipment and

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other goods is less expensive to the Medicaid program than long-

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term rental of the equipment or goods. The agency may establish

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rules to facilitate purchases in lieu of long-term rentals in

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order to protect against fraud and abuse in the Medicaid program

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as defined in s. 409.913. The agency may seek federal waivers

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necessary to administer these policies.

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     (4)  The agency may contract with:

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     (b)  An entity that is providing comprehensive behavioral

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health care services to certain Medicaid recipients through a

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capitated, prepaid arrangement pursuant to the federal waiver

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provided for by s. 409.905(5). Such an entity must be licensed

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under chapter 624, chapter 636, or chapter 641 and must possess

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the clinical systems and operational competence to manage risk

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and provide comprehensive behavioral health care to Medicaid

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recipients. As used in this paragraph, the term "comprehensive

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behavioral health care services" means covered mental health and

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substance abuse treatment services that are available to Medicaid

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recipients. The secretary of the Department of Children and

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Family Services shall approve provisions of procurements related

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to children in the department's care or custody prior to

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enrolling such children in a prepaid behavioral health plan. Any

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contract awarded under this paragraph must be competitively

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procured. In developing the behavioral health care prepaid plan

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procurement document, the agency shall ensure that the

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procurement document requires the contractor to develop and

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implement a plan to ensure compliance with s. 394.4574 related to

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services provided to residents of licensed assisted living

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facilities that hold a limited mental health license. Except as

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provided in subparagraph 8., and except in counties where the

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Medicaid managed care pilot program is authorized pursuant to s.

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409.91211, the agency shall seek federal approval to contract

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with a single entity meeting these requirements to provide

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comprehensive behavioral health care services to all Medicaid

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recipients not enrolled in a Medicaid managed care plan

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authorized under s. 409.91211 or a Medicaid health maintenance

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

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managed care pilot program is authorized pursuant to s. 409.91211

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in one or more counties, the agency may procure a contract with a

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single entity to serve the remaining counties as an AHCA area or

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the remaining counties may be included with an adjacent AHCA area

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and shall be subject to this paragraph. Each entity must offer

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sufficient choice of providers in its network to ensure recipient

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access to care and the opportunity to select a provider with whom

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they are satisfied. The network shall include all public mental

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health hospitals. To ensure unimpaired access to behavioral

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health care services by Medicaid recipients, all contracts issued

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pursuant to this paragraph shall require 80 percent of the

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capitation paid to the managed care plan, including health

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maintenance organizations, to be expended for the provision of

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behavioral health care services. In the event the managed care

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plan expends less than 80 percent of the capitation paid pursuant

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to this paragraph for the provision of behavioral health care

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

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agency shall provide the managed care plan with a certification

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letter indicating the amount of capitation paid during each

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calendar year for the provision of behavioral health care

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services pursuant to this section. The agency may reimburse for

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substance abuse treatment services on a fee-for-service basis

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until the agency finds that adequate funds are available for

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capitated, prepaid arrangements.

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

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contracts with the entities providing comprehensive inpatient and

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outpatient mental health care services to Medicaid recipients in

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Hillsborough, Highlands, Hardee, Manatee, and Polk Counties, to

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include substance abuse treatment services.

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

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Children and Family Services shall execute a written agreement

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that requires collaboration and joint development of all policy,

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budgets, procurement documents, contracts, and monitoring plans

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that have an impact on the state and Medicaid community mental

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health and targeted case management programs.

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     3.  Except as provided in subparagraph 8., by July 1, 2006,

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the agency and the Department of Children and Family Services

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shall contract with managed care entities in each AHCA area

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except area 6 or arrange to provide comprehensive inpatient and

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outpatient mental health and substance abuse services through

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capitated prepaid arrangements to all Medicaid recipients who are

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eligible to participate in such plans under federal law and

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regulation. In AHCA areas where eligible individuals number less

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than 150,000, the agency shall contract with a single managed

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care plan to provide comprehensive behavioral health services to

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all recipients who are not enrolled in a Medicaid health

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maintenance organization or a Medicaid capitated managed care

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plan authorized under s. 409.91211. The agency may contract with

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more than one comprehensive behavioral health provider to provide

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care to recipients who are not enrolled in a Medicaid capitated

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managed care plan authorized under s. 409.91211 or a Medicaid

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health maintenance organization in AHCA areas where the eligible

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

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managed care pilot program is authorized pursuant to s. 409.91211

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in one or more counties, the agency may procure a contract with a

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single entity to serve the remaining counties as an AHCA area or

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the remaining counties may be included with an adjacent AHCA area

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and shall be subject to this paragraph. Contracts for

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comprehensive behavioral health providers awarded pursuant to

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this section shall be competitively procured. Both for-profit and

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not-for-profit corporations shall be eligible to compete. Managed

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care plans contracting with the agency under subsection (3) shall

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provide and receive payment for the same comprehensive behavioral

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health benefits as provided in AHCA rules, including handbooks

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incorporated by reference. In AHCA area 11, the agency shall

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contract with at least two comprehensive behavioral health care

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providers to provide behavioral health care to recipients in that

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area who are enrolled in, or assigned to, the MediPass program.

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One of the behavioral health care contracts shall be with the

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existing provider service network pilot project, as described in

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paragraph (d), for the purpose of demonstrating the cost-

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effectiveness of the provision of quality mental health services

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through a public hospital-operated managed care model. Payment

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shall be at an agreed-upon capitated rate to ensure cost savings.

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Of the recipients in area 11 who are assigned to MediPass under

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the provisions of s. 409.9122(2)(k), a minimum of 50,000 of those

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MediPass-enrolled recipients shall be assigned to the existing

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provider service network in area 11 for their behavioral care.

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

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submit a plan to the Governor, the President of the Senate, and

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the Speaker of the House of Representatives which provides for

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the full implementation of capitated prepaid behavioral health

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care in all areas of the state.

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     a.  Implementation shall begin in 2003 in those AHCA areas

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of the state where the agency is able to establish sufficient

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capitation rates.

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     b.  If the agency determines that the proposed capitation

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rate in any area is insufficient to provide appropriate services,

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the agency may adjust the capitation rate to ensure that care

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will be available. The agency and the department may use existing

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general revenue to address any additional required match but may

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not over-obligate existing funds on an annualized basis.

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     c.  Subject to any limitations provided for in the General

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Appropriations Act, the agency, in compliance with appropriate

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federal authorization, shall develop policies and procedures that

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allow for certification of local and state funds.

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     5.  Children residing in a statewide inpatient psychiatric

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

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of Children and Family Services residential program approved as a

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Medicaid behavioral health overlay services provider shall not be

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included in a behavioral health care prepaid health plan or any

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other Medicaid managed care plan pursuant to this paragraph.

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

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agency shall in its procurement document require an entity

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providing only comprehensive behavioral health care services to

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prevent the displacement of indigent care patients by enrollees

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in the Medicaid prepaid health plan providing behavioral health

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care services from facilities receiving state funding to provide

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indigent behavioral health care, to facilities licensed under

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chapter 395 which do not receive state funding for indigent

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behavioral health care, or reimburse the unsubsidized facility

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for the cost of behavioral health care provided to the displaced

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indigent care patient.

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     7.  Traditional community mental health providers under

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contract with the Department of Children and Family Services

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

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contract with the Department of Children and Family Services in

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areas 1 and 6, and inpatient mental health providers licensed

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pursuant to chapter 395 must be offered an opportunity to accept

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or decline a contract to participate in any provider network for

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prepaid behavioral health services.

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

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

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for child welfare services in the HomeSafeNet system, shall be

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enrolled in MediPass or in Medicaid fee-for-service and all their

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behavioral health care services including inpatient, outpatient

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psychiatric, community mental health, and case management shall

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be reimbursed on a fee-for-service basis. Beginning July 1, 2005,

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such children, who are open for child welfare services in the

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HomeSafeNet system, shall receive their behavioral health care

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services through a specialty prepaid plan operated by community-

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based lead agencies either through a single agency or formal

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agreements among several agencies. The specialty prepaid plan

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must result in savings to the state comparable to savings

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achieved in other Medicaid managed care and prepaid programs.

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Such plan must provide mechanisms to maximize state and local

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revenues. The specialty prepaid plan shall be developed by the

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agency and the Department of Children and Family Services. The

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agency is authorized to seek any federal waivers to implement

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this initiative. Medicaid-eligible children whose cases are open

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for child welfare services in the HomeSafeNet system and who

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

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upon the development of a service delivery mechanism for children

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who reside in area 10 as specified in s. 409.91211(3)(dd).

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     9. An entity providing comprehensive behavioral health care

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services and licensed under chapter 624, chapter 636, or chapter

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641 shall:

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     a. Continue services authorized by the previous entity as

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medically necessary while prior authorization is being processed

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under a new plan;

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     b. Pay, within 10 business days after receipt, electronic

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clean claims containing sufficient information for processing.

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For purposes of this paragraph, the term "clean claim" means a

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claim that does not have any defect or impropriety, including the

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lack of any required substantiating documentation or particular

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circumstance requiring special treatment that prevents timely

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payment being made; and

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     c. Develop and maintain an informal grievance system that

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addresses payment and contract problems with physicians licensed

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under chapter 458 or chapter 459, psychologists licensed under

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chapter 491, psychotherapists as defined in chapter 491, or a

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facility operating under chapter 393, chapter 394, or chapter

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397. The agency shall also establish a formal grievance system to

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address those issues that were not resolved through the informal

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grievance system.

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     Section 2.  This act shall take effect July 1, 2008.