HB 691

1	A bill to be entitled
2	An act relating to Medicaid recipients with psychiatric
3	disabilities ; amending s. 409.912, F.S.; authorizing the
4	Agency for Health Care Administration to contract with
5	certain service networks that enroll Medicaid recipients
6	with psychiatric disabilities; providing for recipients
7	with psychiatric disabilities to be assigned to a
8	specified service network under certain circumstances;
9	amending s. 409.91211, F.S.; revising duties of the agency
10	to include contracting with provider service networks
11	specializing in care for Medicaid recipients with
12	psychiatric disabilities; revising criteria for assignment
13	of certain Medicaid recipients; providing an effective
14	date.
15
16	Be It Enacted by the Legislature of the State of Florida:
17
18	Section 1.  Paragraph (d) of subsection (4) of section
19	409.912, Florida Statutes, is amended to read:
20	409.912  Cost-effective purchasing of health care.--The
21	agency shall purchase goods and services for Medicaid recipients
22	in the most cost-effective manner consistent with the delivery
23	of quality medical care. To ensure that medical services are
24	effectively utilized, the agency may, in any case, require a
25	confirmation or second physician's opinion of the correct
26	diagnosis for purposes of authorizing future services under the
27	Medicaid program. This section does not restrict access to
28	emergency services or poststabilization care services as defined
29	in 42 C.F.R. part 438.114. Such confirmation or second opinion
30	shall be rendered in a manner approved by the agency. The agency
31	shall maximize the use of prepaid per capita and prepaid
32	aggregate fixed-sum basis services when appropriate and other
33	alternative service delivery and reimbursement methodologies,
34	including competitive bidding pursuant to s. 287.057, designed
35	to facilitate the cost-effective purchase of a case-managed
36	continuum of care. The agency shall also require providers to
37	minimize the exposure of recipients to the need for acute
38	inpatient, custodial, and other institutional care and the
39	inappropriate or unnecessary use of high-cost services. The
40	agency shall contract with a vendor to monitor and evaluate the
41	clinical practice patterns of providers in order to identify
42	trends that are outside the normal practice patterns of a
43	provider's professional peers or the national guidelines of a
44	provider's professional association. The vendor must be able to
45	provide information and counseling to a provider whose practice
46	patterns are outside the norms, in consultation with the agency,
47	to improve patient care and reduce inappropriate utilization.
48	The agency may mandate prior authorization, drug therapy
49	management, or disease management participation for certain
50	populations of Medicaid beneficiaries, certain drug classes, or
51	particular drugs to prevent fraud, abuse, overuse, and possible
52	dangerous drug interactions. The Pharmaceutical and Therapeutics
53	Committee shall make recommendations to the agency on drugs for
54	which prior authorization is required. The agency shall inform
55	the Pharmaceutical and Therapeutics Committee of its decisions
56	regarding drugs subject to prior authorization. The agency is
57	authorized to limit the entities it contracts with or enrolls as
58	Medicaid providers by developing a provider network through
59	provider credentialing. The agency may competitively bid single-
60	source-provider contracts if procurement of goods or services
61	results in demonstrated cost savings to the state without
62	limiting access to care. The agency may limit its network based
63	on the assessment of beneficiary access to care, provider
64	availability, provider quality standards, time and distance
65	standards for access to care, the cultural competence of the
66	provider network, demographic characteristics of Medicaid
67	beneficiaries, practice and provider-to-beneficiary standards,
68	appointment wait times, beneficiary use of services, provider
69	turnover, provider profiling, provider licensure history,
70	previous program integrity investigations and findings, peer
71	review, provider Medicaid policy and billing compliance records,
72	clinical and medical record audits, and other factors. Providers
73	shall not be entitled to enrollment in the Medicaid provider
74	network. The agency shall determine instances in which allowing
75	Medicaid beneficiaries to purchase durable medical equipment and
76	other goods is less expensive to the Medicaid program than long-
77	term rental of the equipment or goods. The agency may establish
78	rules to facilitate purchases in lieu of long-term rentals in
79	order to protect against fraud and abuse in the Medicaid program
80	as defined in s. 409.913. The agency may seek federal waivers
81	necessary to administer these policies.
82	(4)  The agency may contract with:
83	(d)  A provider service network, which may be reimbursed on
84	a fee-for-service or prepaid basis. A provider service network
85	which is reimbursed by the agency on a prepaid basis shall be
86	exempt from parts I and III of chapter 641, but must comply with
87	the solvency requirements in s. 641.2261(2) and meet appropriate
88	financial reserve, quality assurance, and patient rights
89	requirements as established by the agency. The agency is
90	authorized to contract with specialty provider service networks
91	that exclusively enroll Medicaid recipients with psychiatric
92	disabilities.
93	1.  Except as provided in subparagraph 2., Medicaid
94	recipients assigned to a provider service network shall be
95	chosen equally from those who would otherwise have been assigned
96	to prepaid plans and MediPass. The agency is authorized to seek
97	federal Medicaid waivers as necessary to implement the
98	provisions of this section. Any contract previously awarded to a
99	provider service network operated by a hospital pursuant to this
100	subsection shall remain in effect for a period of 3 years
101	following the current contract expiration date, regardless of
102	any contractual provisions to the contrary. A provider service
103	network is a network established or organized and operated by a
104	health care provider, or group of affiliated health care
105	providers, including minority physician networks and emergency
106	room diversion programs that meet the requirements of s.
107	409.91211, which provides a substantial proportion of the health
108	care items and services under a contract directly through the
109	provider or affiliated group of providers and may make
110	arrangements with physicians or other health care professionals,
111	health care institutions, or any combination of such individuals
112	or institutions to assume all or part of the financial risk on a
113	prospective basis for the provision of basic health services by
114	the physicians, by other health professionals, or through the
115	institutions. The health care providers must have a controlling
116	interest in the governing body of the provider service network
117	organization.
118	2.  A Medicaid recipient with psychiatric disabilities who
119	fails to select a managed care plan shall be assigned to a
120	provider service network that exclusively enrolls Medicaid
121	recipients with psychiatric disabilities, if such program is
122	available in the geographic area where the recipient resides.
123	Section 2.  Paragraph (a) of subsection (4) of section
124	409.91211, Florida Statutes, is amended, and paragraph (ee) is
125	added to subsection (3) of that section, to read:
126	409.91211  Medicaid managed care pilot program.--
127	(3)  The agency shall have the following powers, duties,
128	and responsibilities with respect to the pilot program:
129	(ee)  To seek applications for and contract with provider
130	service networks specializing in care for recipients with
131	psychiatric disabilities. The agency shall develop and implement
132	a definition of psychiatric disabilities for membership and
133	assignment purposes and establish assignment processes for
134	recipients with psychiatric disabilities who fail to choose a
135	managed care plan.
136	(4)(a)  A Medicaid recipient in the pilot area who is not
137	currently enrolled in a capitated managed care plan upon
138	implementation is not eligible for services as specified in ss.
139	409.905 and 409.906, for the amount of time that the recipient
140	does not enroll in a capitated managed care network. If a
141	Medicaid recipient has not enrolled in a capitated managed care
142	plan within 30 days after eligibility, the agency shall assign
143	the Medicaid recipient to a capitated managed care plan based on
144	the assessed needs of the recipient as determined by the agency
145	and the recipient shall be exempt from s. 409.9122. When making
146	assignments, the agency shall take into account the following
147	criteria:
148	1.  A capitated managed care network has sufficient network
149	capacity to meet the needs of members.
150	2.  The capitated managed care network has previously
151	enrolled the recipient as a member, or one of the capitated
152	managed care network's primary care providers has previously
153	provided health care to the recipient.
154	3.  The agency has knowledge that the member has previously
155	expressed a preference for a particular capitated managed care
156	network as indicated by Medicaid fee-for-service claims data,
157	but has failed to make a choice.
158	4.  The capitated managed care network's primary care
159	providers are geographically accessible to the recipient's
160	residence.
161	5.  The existence of any known diagnoses or disabilities,
162	including psychiatric disabilities.
163	Section 3.  This act shall take effect July 1, 2008.

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