Amendment
Bill No. 0881

Amendment No. 336335

CHAMBER ACTION
Senate		House
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1	Representative(s) Sands offered the following:
2
3	Amendment (with title amendment)
4	Between line(s) 152 and 153, insert:
5	Section 4.  Paragraph (b) of subsection (4) of section
6	409.912, Florida Statutes, is amended to read:
7	409.912  Cost-effective purchasing of health care.--The
8	agency shall purchase goods and services for Medicaid recipients
9	in the most cost-effective manner consistent with the delivery
10	of quality medical care. To ensure that medical services are
11	effectively utilized, the agency may, in any case, require a
12	confirmation or second physician's opinion of the correct
13	diagnosis for purposes of authorizing future services under the
14	Medicaid program. This section does not restrict access to
15	emergency services or poststabilization care services as defined
16	in 42 C.F.R. part 438.114. Such confirmation or second opinion
17	shall be rendered in a manner approved by the agency. The agency
18	shall maximize the use of prepaid per capita and prepaid
19	aggregate fixed-sum basis services when appropriate and other
20	alternative service delivery and reimbursement methodologies,
21	including competitive bidding pursuant to s. 287.057, designed
22	to facilitate the cost-effective purchase of a case-managed
23	continuum of care. The agency shall also require providers to
24	minimize the exposure of recipients to the need for acute
25	inpatient, custodial, and other institutional care and the
26	inappropriate or unnecessary use of high-cost services. The
27	agency may mandate prior authorization, drug therapy management,
28	or disease management participation for certain populations of
29	Medicaid beneficiaries, certain drug classes, or particular
30	drugs to prevent fraud, abuse, overuse, and possible dangerous
31	drug interactions. The Pharmaceutical and Therapeutics Committee
32	shall make recommendations to the agency on drugs for which
33	prior authorization is required. The agency shall inform the
34	Pharmaceutical and Therapeutics Committee of its decisions
35	regarding drugs subject to prior authorization. The agency is
36	authorized to limit the entities it contracts with or enrolls as
37	Medicaid providers by developing a provider network through
38	provider credentialing. The agency may limit its network based
39	on the assessment of beneficiary access to care, provider
40	availability, provider quality standards, time and distance
41	standards for access to care, the cultural competence of the
42	provider network, demographic characteristics of Medicaid
43	beneficiaries, practice and provider-to-beneficiary standards,
44	appointment wait times, beneficiary use of services, provider
45	turnover, provider profiling, provider licensure history,
46	previous program integrity investigations and findings, peer
47	review, provider Medicaid policy and billing compliance records,
48	clinical and medical record audits, and other factors. Providers
49	shall not be entitled to enrollment in the Medicaid provider
50	network. The agency is authorized to seek federal waivers
51	necessary to implement this policy.
52	(4)  The agency may contract with:
53	(b)  An entity that is providing comprehensive behavioral
54	health care services to certain Medicaid recipients through a
55	capitated, prepaid arrangement pursuant to the federal waiver
56	provided for by s. 409.905(5). Such an entity must be licensed
57	under chapter 624, chapter 636, or chapter 641 and must possess
58	the clinical systems and operational competence to manage risk
59	and provide comprehensive behavioral health care to Medicaid
60	recipients. As used in this paragraph, the term "comprehensive
61	behavioral health care services" means covered mental health and
62	substance abuse treatment services that are available to
63	Medicaid recipients. The secretary of the Department of Children
64	and Family Services shall approve provisions of procurements
65	related to children in the department's care or custody prior to
66	enrolling such children in a prepaid behavioral health plan. Any
67	contract awarded under this paragraph must be competitively
68	procured. In developing the behavioral health care prepaid plan
69	procurement document, the agency shall ensure that the
70	procurement document requires the contractor to develop and
71	implement a plan to ensure compliance with s. 394.4574 related
72	to services provided to residents of licensed assisted living
73	facilities that hold a limited mental health license. Except as
74	provided in subparagraph 8., the agency shall seek federal
75	approval to contract with a single entity meeting these
76	requirements to provide comprehensive behavioral health care
77	services to all Medicaid recipients not enrolled in a managed
78	care plan in an AHCA area. Each entity must offer sufficient
79	choice of providers in its network to ensure recipient access to
80	care and the opportunity to select a provider with whom they are
81	satisfied. The network shall include all public mental health
82	hospitals. To ensure unimpaired access to behavioral health care
83	services by Medicaid recipients, all contracts issued pursuant
84	to this paragraph shall require 80 percent of the capitation
85	paid to the managed care plan, including health maintenance
86	organizations, to be expended for the provision of behavioral
87	health care services. In the event the managed care plan expends
88	less than 80 percent of the capitation paid pursuant to this
89	paragraph for the provision of behavioral health care services,
90	the difference shall be returned to the agency. The agency shall
91	provide the managed care plan with a certification letter
92	indicating the amount of capitation paid during each calendar
93	year for the provision of behavioral health care services
94	pursuant to this section. The agency may reimburse for substance
95	abuse treatment services on a fee-for-service basis until the
96	agency finds that adequate funds are available for capitated,
97	prepaid arrangements.
98	1.  By January 1, 2001, the agency shall modify the
99	contracts with the entities providing comprehensive inpatient
100	and outpatient mental health care services to Medicaid
101	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
102	Counties, to include substance abuse treatment services.
103
104	2.  By July 1, 2003, the agency and the Department of
105	Children and Family Services shall execute a written agreement
106	that requires collaboration and joint development of all policy,
107	budgets, procurement documents, contracts, and monitoring plans
108	that have an impact on the state and Medicaid community mental
109	health and targeted case management programs.
110	3.  Except as provided in subparagraph 8., by July 1, 2006,
111	the agency and the Department of Children and Family Services
112	shall contract with managed care entities in each AHCA area
113	except area 6 or arrange to provide comprehensive inpatient and
114	outpatient mental health and substance abuse services through
115	capitated prepaid arrangements to all Medicaid recipients who
116	are eligible to participate in such plans under federal law and
117	regulation. In AHCA areas where eligible individuals number less
118	than 150,000, the agency shall contract with a single managed
119	care plan to provide comprehensive behavioral health services to
120	all recipients who are not enrolled in a Medicaid health
121	maintenance organization. The agency may contract with more than
122	one comprehensive behavioral health provider to provide care to
123	recipients who are not enrolled in a Medicaid health maintenance
124	organization in AHCA areas where the eligible population exceeds
125	150,000. Contracts for comprehensive behavioral health providers
126	awarded pursuant to this section shall be competitively
127	procured. Both for-profit and not-for-profit corporations shall
128	be eligible to compete. Managed care plans contracting with the
129	agency under subsection (3) shall provide and receive payment
130	for the same comprehensive behavioral health benefits as
131	provided in AHCA rules, including handbooks incorporated by
132	reference. Existing provider service networks shall be permitted
133	to continue their programs for a period of no less than 3 years
134	and shall include mental health care and substance abuse
135	programs as part of the services offered by the network.
136	Notwithstanding any other provision of this section, county
137	governments may participate as provider service networks.
138	4.  By October 1, 2003, the agency and the department shall
139	submit a plan to the Governor, the President of the Senate, and
140	the Speaker of the House of Representatives which provides for
141	the full implementation of capitated prepaid behavioral health
142	care in all areas of the state.
143	a.  Implementation shall begin in 2003 in those AHCA areas
144	of the state where the agency is able to establish sufficient
145	capitation rates.
146	b.  If the agency determines that the proposed capitation
147	rate in any area is insufficient to provide appropriate
148	services, the agency may adjust the capitation rate to ensure
149	that care will be available. The agency and the department may
150	use existing general revenue to address any additional required
151	match but may not over-obligate existing funds on an annualized
152	basis.
153	c.  Subject to any limitations provided for in the General
154	Appropriations Act, the agency, in compliance with appropriate
155	federal authorization, shall develop policies and procedures
156	that allow for certification of local and state funds.
157	5.  Children residing in a statewide inpatient psychiatric
158	program, or in a Department of Juvenile Justice or a Department
159	of Children and Family Services residential program approved as
160	a Medicaid behavioral health overlay services provider shall not
161	be included in a behavioral health care prepaid health plan or
162	any other Medicaid managed care plan pursuant to this paragraph.
163	6.  In converting to a prepaid system of delivery, the
164	agency shall in its procurement document require an entity
165	providing only comprehensive behavioral health care services to
166	prevent the displacement of indigent care patients by enrollees
167	in the Medicaid prepaid health plan providing behavioral health
168	care services from facilities receiving state funding to provide
169	indigent behavioral health care, to facilities licensed under
170	chapter 395 which do not receive state funding for indigent
171	behavioral health care, or reimburse the unsubsidized facility
172	for the cost of behavioral health care provided to the displaced
173	indigent care patient.
174	7.  Traditional community mental health providers under
175	contract with the Department of Children and Family Services
176	pursuant to part IV of chapter 394, child welfare providers
177	under contract with the Department of Children and Family
178	Services in areas 1 and 6, and inpatient mental health providers
179	licensed pursuant to chapter 395 must be offered an opportunity
180	to accept or decline a contract to participate in any provider
181	network for prepaid behavioral health services.
182	8.  For fiscal year 2004-2005, all Medicaid eligible
183	children, except children in areas 1 and 6, whose cases are open
184	for child welfare services in the HomeSafeNet system, shall be
185	enrolled in MediPass or in Medicaid fee-for-service and all
186	their behavioral health care services including inpatient,
187	outpatient psychiatric, community mental health, and case
188	management shall be reimbursed on a fee-for-service basis.
189	Beginning July 1, 2005, such children, who are open for child
190	welfare services in the HomeSafeNet system, shall receive their
191	behavioral health care services through a specialty prepaid plan
192	operated by community-based lead agencies either through a
193	single agency or formal agreements among several agencies. The
194	specialty prepaid plan must result in savings to the state
195	comparable to savings achieved in other Medicaid managed care
196	and prepaid programs. Such plan must provide mechanisms to
197	maximize state and local revenues. The specialty prepaid plan
198	shall be developed by the agency and the Department of Children
199	and Family Services. The agency is authorized to seek any
200	federal waivers to implement this initiative.
201
202
203	================ T I T L E  A M E N D M E N T =============
204	Remove line 28 and insert:
205	amending s. 409.912, F.S.; prohibiting existing provider service
206	networks from continuing their programs for a specified time
207	period; including mental health care and substance abuse
208	programs as services offered by the network; authorizing county
209	governments to participate in provider service networks;
210	providing an effective date.

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