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:
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29 Section 1. Paragraph (d) of subsection (4) of section
30 409.912, Florida Statutes, is amended to read:
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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
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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
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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:
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Florida Senate - 2007 SB 1690
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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
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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
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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
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Florida Senate - 2007 SB 1690
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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
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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
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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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