Senate Bill sb0934c1
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Florida Senate - 2007 CS for SB 934
By the Committee on Health Policy; and Senator Dawson
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1 A bill to be entitled
2 An act relating to Medicaid services for
3 children; amending s. 409.912, F.S.; providing
4 for children who are eligible for Medicaid and
5 who reside in an area in which a managed care
6 pilot program has been implemented to receive
7 behavioral health care services under the pilot
8 program rather than under a specialty prepaid
9 plan developed by the Agency for Health Care
10 Administration and the Department of Children
11 and Family Services; amending s. 409.91211,
12 F.S., relating to the Medicaid managed care
13 pilot program; revising duties of the agency
14 with respect to providing Medicaid services to
15 children; requiring that such services include
16 certain behavioral health services; requiring
17 that the service-delivery mechanisms be
18 implemented by a specified date; providing an
19 effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
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23 Section 1. Paragraph (b) of subsection (4) of section
24 409.912, Florida Statutes, is amended to read:
25 409.912 Cost-effective purchasing of health care.--The
26 agency shall purchase goods and services for Medicaid
27 recipients in the most cost-effective manner consistent with
28 the delivery of quality medical care. To ensure that medical
29 services are effectively utilized, the agency may, in any
30 case, require a confirmation or second physician's opinion of
31 the correct diagnosis for purposes of authorizing future
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1 services under the Medicaid program. This section does not
2 restrict access to emergency services or poststabilization
3 care services as defined in 42 C.F.R. part 438.114. Such
4 confirmation or second opinion shall be rendered in a manner
5 approved by the agency. The agency shall maximize the use of
6 prepaid per capita and prepaid aggregate fixed-sum basis
7 services when appropriate and other alternative service
8 delivery and reimbursement methodologies, including
9 competitive bidding pursuant to s. 287.057, designed to
10 facilitate the cost-effective purchase of a case-managed
11 continuum of care. The agency shall also require providers to
12 minimize the exposure of recipients to the need for acute
13 inpatient, custodial, and other institutional care and the
14 inappropriate or unnecessary use of high-cost services. The
15 agency shall contract with a vendor to monitor and evaluate
16 the clinical practice patterns of providers in order to
17 identify trends that are outside the normal practice patterns
18 of a provider's professional peers or the national guidelines
19 of a provider's professional association. The vendor must be
20 able to provide information and counseling to a provider whose
21 practice patterns are outside the norms, in consultation with
22 the agency, to improve patient care and reduce inappropriate
23 utilization. The agency may mandate prior authorization, drug
24 therapy management, or disease management participation for
25 certain populations of Medicaid beneficiaries, certain drug
26 classes, or particular drugs to prevent fraud, abuse, overuse,
27 and possible dangerous drug interactions. The Pharmaceutical
28 and Therapeutics Committee shall make recommendations to the
29 agency on drugs for which prior authorization is required. The
30 agency shall inform the Pharmaceutical and Therapeutics
31 Committee of its decisions regarding drugs subject to prior
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1 authorization. The agency is authorized to limit the entities
2 it contracts with or enrolls as Medicaid providers by
3 developing a provider network through provider credentialing.
4 The agency may competitively bid single-source-provider
5 contracts if procurement of goods or services results in
6 demonstrated cost savings to the state without limiting access
7 to care. The agency may limit its network based on the
8 assessment of beneficiary access to care, provider
9 availability, provider quality standards, time and distance
10 standards for access to care, the cultural competence of the
11 provider network, demographic characteristics of Medicaid
12 beneficiaries, practice and provider-to-beneficiary standards,
13 appointment wait times, beneficiary use of services, provider
14 turnover, provider profiling, provider licensure history,
15 previous program integrity investigations and findings, peer
16 review, provider Medicaid policy and billing compliance
17 records, clinical and medical record audits, and other
18 factors. Providers shall not be entitled to enrollment in the
19 Medicaid provider network. The agency shall determine
20 instances in which allowing Medicaid beneficiaries to purchase
21 durable medical equipment and other goods is less expensive to
22 the Medicaid program than long-term rental of the equipment or
23 goods. The agency may establish rules to facilitate purchases
24 in lieu of long-term rentals in order to protect against fraud
25 and abuse in the Medicaid program as defined in s. 409.913.
26 The agency may seek federal waivers necessary to administer
27 these policies.
28 (4) The agency may contract with:
29 (b) An entity that is providing comprehensive
30 behavioral health care services to certain Medicaid recipients
31 through a capitated, prepaid arrangement pursuant to the
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1 federal waiver provided for by s. 409.905(5). Such an entity
2 must be licensed under chapter 624, chapter 636, or chapter
3 641 and must possess the clinical systems and operational
4 competence to manage risk and provide comprehensive behavioral
5 health care to Medicaid recipients. As used in this paragraph,
6 the term "comprehensive behavioral health care services" means
7 covered mental health and substance abuse treatment services
8 that are available to Medicaid recipients. The secretary of
9 the Department of Children and Family Services shall approve
10 provisions of procurements related to children in the
11 department's care or custody prior to enrolling such children
12 in a prepaid behavioral health plan. Any contract awarded
13 under this paragraph must be competitively procured. In
14 developing the behavioral health care prepaid plan procurement
15 document, the agency shall ensure that the procurement
16 document requires the contractor to develop and implement a
17 plan to ensure compliance with s. 394.4574 related to services
18 provided to residents of licensed assisted living facilities
19 that hold a limited mental health license. Except as provided
20 in subparagraph 8., and except in counties where the Medicaid
21 managed care pilot program is authorized pursuant to s.
22 409.91211, the agency shall seek federal approval to contract
23 with a single entity meeting these requirements to provide
24 comprehensive behavioral health care services to all Medicaid
25 recipients not enrolled in a Medicaid managed care plan
26 authorized under s. 409.91211 or a Medicaid health maintenance
27 organization in an AHCA area. In an AHCA area where the
28 Medicaid managed care pilot program is authorized pursuant to
29 s. 409.91211 in one or more counties, the agency may procure a
30 contract with a single entity to serve the remaining counties
31 as an AHCA area or the remaining counties may be included with
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1 an adjacent AHCA area and shall be subject to this paragraph.
2 Each entity must offer sufficient choice of providers in its
3 network to ensure recipient access to care and the opportunity
4 to select a provider with whom they are satisfied. The network
5 shall include all public mental health hospitals. To ensure
6 unimpaired access to behavioral health care services by
7 Medicaid recipients, all contracts issued pursuant to this
8 paragraph shall require 80 percent of the capitation paid to
9 the managed care plan, including health maintenance
10 organizations, to be expended for the provision of behavioral
11 health care services. In the event the managed care plan
12 expends less than 80 percent of the capitation paid pursuant
13 to this paragraph for the provision of behavioral health care
14 services, the difference shall be returned to the agency. The
15 agency shall provide the managed care plan with a
16 certification letter indicating the amount of capitation paid
17 during each calendar year for the provision of behavioral
18 health care services pursuant to this section. The agency may
19 reimburse for substance abuse treatment services on a
20 fee-for-service basis until the agency finds that adequate
21 funds are available for capitated, prepaid arrangements.
22 1. By January 1, 2001, the agency shall modify the
23 contracts with the entities providing comprehensive inpatient
24 and outpatient mental health care services to Medicaid
25 recipients in Hillsborough, Highlands, Hardee, Manatee, and
26 Polk Counties, to include substance abuse treatment services.
27 2. By July 1, 2003, the agency and the Department of
28 Children and Family Services shall execute a written agreement
29 that requires collaboration and joint development of all
30 policy, budgets, procurement documents, contracts, and
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1 monitoring plans that have an impact on the state and Medicaid
2 community mental health and targeted case management programs.
3 3. Except as provided in subparagraph 8., by July 1,
4 2006, the agency and the Department of Children and Family
5 Services shall contract with managed care entities in each
6 AHCA area except area 6 or arrange to provide comprehensive
7 inpatient and outpatient mental health and substance abuse
8 services through capitated prepaid arrangements to all
9 Medicaid recipients who are eligible to participate in such
10 plans under federal law and regulation. In AHCA areas where
11 eligible individuals number less than 150,000, the agency
12 shall contract with a single managed care plan to provide
13 comprehensive behavioral health services to all recipients who
14 are not enrolled in a Medicaid health maintenance organization
15 or a Medicaid capitated managed care plan authorized under s.
16 409.91211. The agency may contract with more than one
17 comprehensive behavioral health provider to provide care to
18 recipients who are not enrolled in a Medicaid capitated
19 managed care plan authorized under s. 409.91211 or a Medicaid
20 health maintenance organization in AHCA areas where the
21 eligible population exceeds 150,000. In an AHCA area where the
22 Medicaid managed care pilot program is authorized pursuant to
23 s. 409.91211 in one or more counties, the agency may procure a
24 contract with a single entity to serve the remaining counties
25 as an AHCA area or the remaining counties may be included with
26 an adjacent AHCA area and shall be subject to this paragraph.
27 Contracts for comprehensive behavioral health providers
28 awarded pursuant to this section shall be competitively
29 procured. Both for-profit and not-for-profit corporations
30 shall be eligible to compete. Managed care plans contracting
31 with the agency under subsection (3) shall provide and receive
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1 payment for the same comprehensive behavioral health benefits
2 as provided in AHCA rules, including handbooks incorporated by
3 reference. In AHCA area 11, the agency shall contract with at
4 least two comprehensive behavioral health care providers to
5 provide behavioral health care to recipients in that area who
6 are enrolled in, or assigned to, the MediPass program. One of
7 the behavioral health care contracts shall be with the
8 existing provider service network pilot project, as described
9 in paragraph (d), for the purpose of demonstrating the
10 cost-effectiveness of the provision of quality mental health
11 services through a public hospital-operated managed care
12 model. Payment shall be at an agreed-upon capitated rate to
13 ensure cost savings. Of the recipients in area 11 who are
14 assigned to MediPass under the provisions of s.
15 409.9122(2)(k), a minimum of 50,000 of those MediPass-enrolled
16 recipients shall be assigned to the existing provider service
17 network in area 11 for their behavioral care.
18 4. By October 1, 2003, the agency and the department
19 shall submit a plan to the Governor, the President of the
20 Senate, and the Speaker of the House of Representatives which
21 provides for the full implementation of capitated prepaid
22 behavioral health care in all areas of the state.
23 a. Implementation shall begin in 2003 in those AHCA
24 areas of the state where the agency is able to establish
25 sufficient capitation rates.
26 b. If the agency determines that the proposed
27 capitation rate in any area is insufficient to provide
28 appropriate services, the agency may adjust the capitation
29 rate to ensure that care will be available. The agency and the
30 department may use existing general revenue to address any
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1 additional required match but may not over-obligate existing
2 funds on an annualized basis.
3 c. Subject to any limitations provided for in the
4 General Appropriations Act, the agency, in compliance with
5 appropriate federal authorization, shall develop policies and
6 procedures that allow for certification of local and state
7 funds.
8 5. Children residing in a statewide inpatient
9 psychiatric program, or in a Department of Juvenile Justice or
10 a Department of Children and Family Services residential
11 program approved as a Medicaid behavioral health overlay
12 services provider shall not be included in a behavioral health
13 care prepaid health plan or any other Medicaid managed care
14 plan pursuant to this paragraph.
15 6. In converting to a prepaid system of delivery, the
16 agency shall in its procurement document require an entity
17 providing only comprehensive behavioral health care services
18 to prevent the displacement of indigent care patients by
19 enrollees in the Medicaid prepaid health plan providing
20 behavioral health care services from facilities receiving
21 state funding to provide indigent behavioral health care, to
22 facilities licensed under chapter 395 which do not receive
23 state funding for indigent behavioral health care, or
24 reimburse the unsubsidized facility for the cost of behavioral
25 health care provided to the displaced indigent care patient.
26 7. Traditional community mental health providers under
27 contract with the Department of Children and Family Services
28 pursuant to part IV of chapter 394, child welfare providers
29 under contract with the Department of Children and Family
30 Services in areas 1 and 6, and inpatient mental health
31 providers licensed pursuant to chapter 395 must be offered an
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1 opportunity to accept or decline a contract to participate in
2 any provider network for prepaid behavioral health services.
3 8. For fiscal year 2004-2005, all Medicaid eligible
4 children, except children in areas 1 and 6, whose cases are
5 open for child welfare services in the HomeSafeNet system,
6 shall be enrolled in MediPass or in Medicaid fee-for-service
7 and all their behavioral health care services including
8 inpatient, outpatient psychiatric, community mental health,
9 and case management shall be reimbursed on a fee-for-service
10 basis. Beginning July 1, 2005, such children, who are open for
11 child welfare services in the HomeSafeNet system, shall
12 receive their behavioral health care services through a
13 specialty prepaid plan operated by community-based lead
14 agencies either through a single agency or formal agreements
15 among several agencies. The specialty prepaid plan must result
16 in savings to the state comparable to savings achieved in
17 other Medicaid managed care and prepaid programs. Such plan
18 must provide mechanisms to maximize state and local revenues.
19 The specialty prepaid plan shall be developed by the agency
20 and the Department of Children and Family Services. The agency
21 is authorized to seek any federal waivers to implement this
22 initiative. Medicaid-eligible children whose cases are open
23 for child welfare services in the HomeSafeNet system and who
24 reside in an area in which Medicaid reform, as provided for in
25 s. 409.91211, has been implemented are exempt from this plan
26 upon the development of a service delivery system for these
27 children in the reform area pursuant to the terms in s.
28 409.91211(3)(dd).
29 Section 2. Paragraph (dd) of subsection (3) of section
30 409.91211, Florida Statutes, is amended to read:
31 409.91211 Medicaid managed care pilot program.--
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1 (3) The agency shall have the following powers,
2 duties, and responsibilities with respect to the pilot
3 program:
4 (dd) To implement develop and recommend service
5 delivery mechanisms within a provider service network or
6 capitated managed care plan plans to provide Medicaid services
7 as specified in ss. 409.905 and 409.906 to Medicaid-eligible
8 children who are open for child welfare services in the
9 HomeSafeNet system in foster care. These services must be
10 coordinated with community-based care providers as specified
11 in s. 409.1671 s. 409.1675, where available, and be sufficient
12 to meet the medical, developmental, behavioral, and emotional
13 needs of these children. Covered behavioral health services
14 must include all services currently included in the specialty
15 prepaid plan as implemented pursuant to s. 409.912(4)(b)8.
16 These service-delivery mechanisms must be implemented by July
17 1, 2008, in order for these children to remain exempt from the
18 statewide plan pursuant to s. 409.912(4)(b)8.
19 Section 3. This act shall take effect July 1, 2007.
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21 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
22 Senate Bill 934
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24 The committee substitute no longer provides legislative intent
to revise laws relating to Medicaid. Instead the committee
25 substitute allows children whose cases are open for child
welfare services in the HomeSafetNet system and who reside in
26 a Medicaid reform county to receive services through a
Medicaid reform plan as long as the covered behavioral health
27 services include all services currently included in the
specialty prepaid plan as operated under s. 409.912(4)(b)8,
28 F.S.
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