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 |
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16 | Be It Enacted by the Legislature of the State of Florida: |
17 |
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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. |