Senate Bill sb1690

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    Florida Senate - 2007                                  SB 1690

    By Senator Rich





    34-1390-07                                              See HB

  1                      A bill to be entitled

  2         An act relating to Medicaid provider service

  3         networks; amending s. 409.912, F.S.;

  4         authorizing the Agency for Health Care

  5         Administration to contract with a specialty

  6         provider service network that exclusively

  7         enrolls Medicaid beneficiaries with psychiatric

  8         disabilities; requiring such beneficiaries to

  9         be assigned to a specialty provider service

10         network under certain circumstances; amending

11         s. 409.91211, F.S.; requiring the agency to

12         modify eligibility assignment processes for

13         managed care pilot programs to include

14         specialty plans that specialize in care for

15         beneficiaries with psychiatric disabilities;

16         defining the terms "specialty provider service

17         network" and "specialty managed care plan";

18         requiring the agency to provide a service

19         delivery alternative to provide Medicaid

20         services to persons with psychiatric

21         disabilities and providing for an open

22         enrollment period; providing for an adjustment

23         of a specialty managed care plan's rates under

24         certain circumstances; providing an effective

25         date.

26  

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

28  

29         Section 1.  Paragraph (d) of subsection (4) of section

30  409.912, Florida Statutes, is amended to read:

31  

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1         409.912  Cost-effective purchasing of health care.--The

 2  agency shall purchase goods and services for Medicaid

 3  recipients in the most cost-effective manner consistent with

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

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

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

 7  the correct diagnosis for purposes of authorizing future

 8  services under the Medicaid program. This section does not

 9  restrict access to emergency services or poststabilization

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

11  confirmation or second opinion shall be rendered in a manner

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

13  prepaid per capita and prepaid aggregate fixed-sum basis

14  services when appropriate and other alternative service

15  delivery and reimbursement methodologies, including

16  competitive bidding pursuant to s. 287.057, designed to

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

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

19  minimize the exposure of recipients to the need for acute

20  inpatient, custodial, and other institutional care and the

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

22  agency shall contract with a vendor to monitor and evaluate

23  the clinical practice patterns of providers in order to

24  identify trends that are outside the normal practice patterns

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

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

27  able to provide information and counseling to a provider whose

28  practice patterns are outside the norms, in consultation with

29  the agency, to improve patient care and reduce inappropriate

30  utilization. The agency may mandate prior authorization, drug

31  therapy management, or disease management participation for

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1  certain populations of Medicaid beneficiaries, certain drug

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

 3  and possible dangerous drug interactions. The Pharmaceutical

 4  and Therapeutics Committee shall make recommendations to the

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

 6  agency shall inform the Pharmaceutical and Therapeutics

 7  Committee of its decisions regarding drugs subject to prior

 8  authorization. The agency is authorized to limit the entities

 9  it contracts with or enrolls as Medicaid providers by

10  developing a provider network through provider credentialing.

11  The agency may competitively bid single-source-provider

12  contracts if procurement of goods or services results in

13  demonstrated cost savings to the state without limiting access

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

15  assessment of beneficiary access to care, provider

16  availability, provider quality standards, time and distance

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

18  provider network, demographic characteristics of Medicaid

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

20  appointment wait times, beneficiary use of services, provider

21  turnover, provider profiling, provider licensure history,

22  previous program integrity investigations and findings, peer

23  review, provider Medicaid policy and billing compliance

24  records, clinical and medical record audits, and other

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

26  Medicaid provider network. The agency shall determine

27  instances in which allowing Medicaid beneficiaries to purchase

28  durable medical equipment and other goods is less expensive to

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

30  goods. The agency may establish rules to facilitate purchases

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

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




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

 2  The agency may seek federal waivers necessary to administer

 3  these policies.

 4         (4)  The agency may contract with:

 5         (d)  A provider service network, which may be

 6  reimbursed on a fee-for-service or prepaid basis. A provider

 7  service network that which is reimbursed by the agency on a

 8  prepaid basis shall be exempt from parts I and III of chapter

 9  641, but must comply with the solvency requirements in s.

10  641.2261(2) and meet appropriate financial reserve, quality

11  assurance, and patient rights requirements as established by

12  the agency.

13         1.  Except as provided in subparagraph 2., Medicaid

14  recipients assigned to a provider service network shall be

15  chosen equally from those who would otherwise have been

16  assigned to prepaid plans and MediPass. The agency is

17  authorized to seek federal Medicaid waivers as necessary to

18  implement the provisions of this section. Any contract

19  previously awarded to a provider service network operated by a

20  hospital pursuant to this subsection shall remain in effect

21  for a period of 3 years following the current contract

22  expiration date, regardless of any contractual provisions to

23  the contrary. A provider service network is a network

24  established or organized and operated by a health care

25  provider, or group of affiliated health care providers,

26  including minority physician networks and emergency room

27  diversion programs that meet the requirements of s. 409.91211,

28  which provides a substantial proportion of the health care

29  items and services under a contract directly through the

30  provider or affiliated group of providers and may make

31  arrangements with physicians or other health care

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1  professionals, health care institutions, or any combination of

 2  such individuals or institutions to assume all or part of the

 3  financial risk on a prospective basis for the provision of

 4  basic health services by the physicians, by other health

 5  professionals, or through the institutions. The health care

 6  providers must have a controlling interest in the governing

 7  body of the provider service network organization.

 8         2.  The agency shall seek applications for and is

 9  authorized to contract with a specialty provider service

10  network that exclusively enrolls Medicaid beneficiaries with

11  psychiatric disabilities. Medicaid beneficiaries with

12  psychiatric disabilities who are required but fail to select a

13  managed care plan shall be assigned to the specialty provider

14  service network in those geographic areas where the specialty

15  provider service network is available. For purposes of

16  enrollment, in addition to those who meet the diagnostic

17  criteria indicating a mental illness or emotional disturbance,

18  beneficiaries served by Medicaid-enrolled community mental

19  health agencies or who voluntarily choose the specialty

20  provider service network shall be presumed to meet the plan

21  enrollment criteria.

22         Section 2.  Paragraphs (o) and (aa) of subsection (3),

23  paragraphs (a) through (e) of subsection (4), and subsection

24  (8) of section 409.91211, Florida Statutes, are amended,

25  paragraph (ee) is added to subsection (3), and paragraph (d)

26  is added to subsection (9) of that section, to read:

27         409.91211  Medicaid managed care pilot program.--

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

29  duties, and responsibilities with respect to the pilot

30  program:

31  

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1         (o)  To implement eligibility assignment processes to

 2  facilitate client choice while ensuring pilot programs of

 3  adequate enrollment levels. These processes shall ensure that

 4  pilot sites have sufficient levels of enrollment to conduct a

 5  valid test of the managed care pilot program within a 2-year

 6  timeframe. Eligibility assignment processes shall be modified

 7  as specified in paragraph (aa).

 8         (aa)  To implement a mechanism whereby Medicaid

 9  recipients who are already enrolled in a managed care plan or

10  the MediPass program in the pilot areas shall be offered the

11  opportunity to change to capitated managed care plans on a

12  staggered basis, as defined by the agency. All Medicaid

13  recipients shall have 30 days in which to make a choice of

14  capitated managed care plans. Those Medicaid recipients who do

15  not make a choice shall be assigned to a capitated managed

16  care plan in accordance with paragraph (4)(a) and shall be

17  exempt from s. 409.9122. To facilitate continuity of care for

18  a Medicaid recipient who is also a recipient of Supplemental

19  Security Income (SSI), prior to assigning the SSI recipient to

20  a capitated managed care plan, the agency shall determine

21  whether the SSI recipient has an ongoing relationship with a

22  provider, including a community mental health provider or

23  capitated managed care plan, and, if so, the agency shall

24  assign the SSI recipient to that provider, provider service

25  network, or capitated managed care plan where feasible. Those

26  SSI recipients who do not have such a provider relationship

27  shall be assigned to a capitated managed care plan provider in

28  accordance with this paragraph and paragraphs (4)(a), (b),

29  (d), and (e) and shall be exempt from s. 409.9122. If an

30  application for a provider service network or capitated

31  managed care plan that specializes in the care of

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1  beneficiaries with psychiatric disabilities is being

 2  considered in a geographic area, reform plans shall not be

 3  available for enrollment until the specialty plan is available

 4  as a choice to beneficiaries. For the purposes of this

 5  section, a "specialty provider service network" or "specialty

 6  managed care plan" means a provider service or managed care

 7  plan that limits plan enrollment to individuals with specific

 8  diagnoses.

 9         (ee)  To develop and implement a service delivery

10  alternative within capitated managed care plans to provide

11  Medicaid services as specified in ss. 409.905 and 409.906 for

12  persons with psychiatric disabilities sufficient to meet the

13  medical, developmental, and emotional needs of those persons.

14         (4)(a)  A Medicaid recipient in the pilot area who is

15  not currently enrolled in a capitated managed care plan upon

16  implementation is not eligible for services as specified in

17  ss. 409.905 and 409.906, for the amount of time that the

18  recipient does not enroll in a capitated managed care network.

19  If a Medicaid recipient has not enrolled in a capitated

20  managed care plan within 30 days after eligibility, the agency

21  shall assign the Medicaid recipient to a capitated managed

22  care plan based on the assessed needs of the recipient as

23  determined by the agency and the recipient shall be exempt

24  from s. 409.9122. When making assignments, the agency shall

25  take into account the following criteria:

26         1.  A capitated managed care network has sufficient

27  network capacity to meet the needs of members.

28         2.  The capitated managed care network has previously

29  enrolled the recipient as a member, or one of the capitated

30  managed care network's primary care providers has previously

31  provided health care to the recipient.

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1         3.  The agency has knowledge that the member has

 2  previously expressed a preference for a particular capitated

 3  managed care network as indicated by Medicaid fee-for-service

 4  claims data, but has failed to make a choice.

 5         4.  The capitated managed care network's primary care

 6  providers are geographically accessible to the recipient's

 7  residence.

 8         5.  The extent of the psychiatric disability of the

 9  Medicaid beneficiary.

10         (b)  When more than one capitated managed care network

11  provider meets the criteria specified in paragraph (3)(h), the

12  agency shall assess a beneficiary's psychiatric disability

13  before making an assignment and make recipient assignments

14  consecutively by family unit.

15         (c)  If a recipient is currently enrolled with a

16  Medicaid managed care organization that also operates an

17  approved reform plan within a demonstration area and the

18  recipient fails to choose a plan during the reform enrollment

19  process or during redetermination of eligibility, the

20  recipient shall be automatically assigned by the agency into

21  the most appropriate reform plan operated by the recipient's

22  current Medicaid managed care plan. If the recipient's current

23  managed care plan does not operate a reform plan in the

24  demonstration area which adequately meets the needs of the

25  Medicaid recipient, the agency shall use the automatic

26  assignment process as prescribed in the special terms and

27  conditions numbered 11-W-00206/4. All enrollment and choice

28  counseling materials provided by the agency must contain an

29  explanation of the provisions of this paragraph for current

30  managed care recipients and an explanation of the choice of

31  

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1  any specialty provider service network or specialty managed

 2  care plan.

 3         (d)  Except as provided in paragraph (b), the agency

 4  may not engage in practices that are designed to favor one

 5  capitated managed care plan over another or that are designed

 6  to influence Medicaid recipients to enroll in a particular

 7  capitated managed care network in order to strengthen its

 8  particular fiscal viability.

 9         (e)  After a recipient has made a selection or has been

10  enrolled in a capitated managed care network, the recipient

11  shall have 90 days in which to voluntarily disenroll and

12  select another capitated managed care network. After 90 days,

13  no further changes may be made except for cause. Cause shall

14  include, but not be limited to, poor quality of care, lack of

15  access to necessary specialty services, an unreasonable delay

16  or denial of service, inordinate or inappropriate changes of

17  primary care providers, service access impairments due to

18  significant changes in the geographic location of services, or

19  fraudulent enrollment. The agency may require a recipient to

20  use the capitated managed care network's grievance process as

21  specified in paragraph (3)(g) prior to the agency's

22  determination of cause, except in cases in which immediate

23  risk of permanent damage to the recipient's health is alleged.

24  The grievance process, when used, must be completed in time to

25  permit the recipient to disenroll no later than the first day

26  of the second month after the month the disenrollment request

27  was made. If the capitated managed care network, as a result

28  of the grievance process, approves an enrollee's request to

29  disenroll, the agency is not required to make a determination

30  in the case. The agency must make a determination and take

31  final action on a recipient's request so that disenrollment

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1  occurs no later than the first day of the second month after

 2  the month the request was made. If the agency fails to act

 3  within the specified timeframe, the recipient's request to

 4  disenroll is deemed to be approved as of the date agency

 5  action was required. Recipients who disagree with the agency's

 6  finding that cause does not exist for disenrollment shall be

 7  advised of their right to pursue a Medicaid fair hearing to

 8  dispute the agency's finding. When a specialty provider

 9  service network or specialty managed care plan first becomes

10  available in a geographic area, beneficiaries meeting

11  diagnostic criteria shall be offered an open enrollment period

12  during which they may choose to reenroll in a specialty

13  provider service network or specialty managed care plan.

14         (8)  Except as provided in paragraph (9)(d), the agency

15  must ensure, in the first two state fiscal years in which a

16  risk-adjusted methodology is a component of rate setting, that

17  no managed care plan providing comprehensive benefits to TANF

18  and SSI recipients has an aggregate risk score that varies by

19  more than 10 percent from the aggregate weighted mean of all

20  managed care plans providing comprehensive benefits to TANF

21  and SSI recipients in a reform area. The agency's payment to a

22  managed care plan shall be based on such revised aggregate

23  risk score.

24         (9)  After any calculations of aggregate risk scores or

25  revised aggregate risk scores in subsection (8), the

26  capitation rates for plans participating under this section

27  shall be phased in as follows:

28         (d)  During this modified rate-setting period, a

29  specialty managed care plan's rates may be adjusted by

30  percentages other than those provided in this subsection

31  because of the disproportionate enrollment of individuals with

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    Florida Senate - 2007                                  SB 1690
    34-1390-07                                              See HB




 1  psychiatric disabilities in a specialty provider service

 2  network or specialty managed care plan.

 3         Section 3.  This act shall take effect July 1, 2007.

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