CS/HB 691

1	A bill to be entitled
2	An act relating to Medicaid provider service networks;
3	amending s. 409.912, F.S.; authorizing the Agency for
4	Health Care Administration to contract with a specialty
5	provider service network that exclusively enrolls Medicaid
6	beneficiaries who have psychiatric disabilities; defining
7	"psychiatric disabilities"; requiring the specialty
8	provider to offer the same physical and behavioral health
9	services that are required from other Medicaid health
10	maintenance organizations and provider service networks;
11	requiring that beneficiaries be assigned to a specialty
12	provider service network under certain circumstances;
13	amending s. 409.91211, F.S.; requiring that the agency
14	modify eligibility assignment processes for managed care
15	pilot programs to include specialty plans that specialize
16	in care for beneficiaries who have psychiatric
17	disabilities; requiring the agency to provide a service
18	delivery alternative to provide Medicaid services to
19	persons having psychiatric disabilities; providing an
20	additional criterion for the agency in making assignments;
21	requiring that enrollment and choice counseling materials
22	contain an explanation concerning the choice of a network
23	or plan; providing for an additional open enrollment
24	period following the availability of specialty services;
25	providing an effective 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	409.912  Cost-effective purchasing of health care.--The
32	agency shall purchase goods and services for Medicaid recipients
33	in the most cost-effective manner consistent with the delivery
34	of quality medical care. To ensure that medical services are
35	effectively utilized, the agency may, in any case, require a
36	confirmation or second physician's opinion of the correct
37	diagnosis for purposes of authorizing future services under the
38	Medicaid program. This section does not restrict access to
39	emergency services or poststabilization care services as defined
40	in 42 C.F.R. part 438.114. Such confirmation or second opinion
41	shall be rendered in a manner approved by the agency. The agency
42	shall maximize the use of prepaid per capita and prepaid
43	aggregate fixed-sum basis services when appropriate and other
44	alternative service delivery and reimbursement methodologies,
45	including competitive bidding pursuant to s. 287.057, designed
46	to facilitate the cost-effective purchase of a case-managed
47	continuum of care. The agency shall also require providers to
48	minimize the exposure of recipients to the need for acute
49	inpatient, custodial, and other institutional care and the
50	inappropriate or unnecessary use of high-cost services. The
51	agency shall contract with a vendor to monitor and evaluate the
52	clinical practice patterns of providers in order to identify
53	trends that are outside the normal practice patterns of a
54	provider's professional peers or the national guidelines of a
55	provider's professional association. The vendor must be able to
56	provide information and counseling to a provider whose practice
57	patterns are outside the norms, in consultation with the agency,
58	to improve patient care and reduce inappropriate utilization.
59	The agency may mandate prior authorization, drug therapy
60	management, or disease management participation for certain
61	populations of Medicaid beneficiaries, certain drug classes, or
62	particular drugs to prevent fraud, abuse, overuse, and possible
63	dangerous drug interactions. The Pharmaceutical and Therapeutics
64	Committee shall make recommendations to the agency on drugs for
65	which prior authorization is required. The agency shall inform
66	the Pharmaceutical and Therapeutics Committee of its decisions
67	regarding drugs subject to prior authorization. The agency is
68	authorized to limit the entities it contracts with or enrolls as
69	Medicaid providers by developing a provider network through
70	provider credentialing. The agency may competitively bid single-
71	source-provider contracts if procurement of goods or services
72	results in demonstrated cost savings to the state without
73	limiting access to care. The agency may limit its network based
74	on the assessment of beneficiary access to care, provider
75	availability, provider quality standards, time and distance
76	standards for access to care, the cultural competence of the
77	provider network, demographic characteristics of Medicaid
78	beneficiaries, practice and provider-to-beneficiary standards,
79	appointment wait times, beneficiary use of services, provider
80	turnover, provider profiling, provider licensure history,
81	previous program integrity investigations and findings, peer
82	review, provider Medicaid policy and billing compliance records,
83	clinical and medical record audits, and other factors. Providers
84	shall not be entitled to enrollment in the Medicaid provider
85	network. The agency shall determine instances in which allowing
86	Medicaid beneficiaries to purchase durable medical equipment and
87	other goods is less expensive to the Medicaid program than long-
88	term rental of the equipment or goods. The agency may establish
89	rules to facilitate purchases in lieu of long-term rentals in
90	order to protect against fraud and abuse in the Medicaid program
91	as defined in s. 409.913. The agency may seek federal waivers
92	necessary to administer these policies.
93	(4)  The agency may contract with:
94	(d)  A provider service network, which may be reimbursed on
95	a fee-for-service or prepaid basis. A provider service network
96	that which is reimbursed by the agency on a prepaid basis is
97	shall be exempt from parts I and III of chapter 641, but must
98	comply with the solvency requirements in s. 641.2261(2) and meet
99	appropriate financial reserve, quality assurance, and patient
100	rights requirements as established by the agency.
101	1.  Except as provided in subparagraph 2., Medicaid
102	recipients assigned to a provider service network shall be
103	chosen equally from those who would otherwise have been assigned
104	to prepaid plans and MediPass. The agency is authorized to seek
105	federal Medicaid waivers as necessary to implement the
106	provisions of this section. Any contract previously awarded to a
107	provider service network operated by a hospital pursuant to this
108	subsection shall remain in effect for a period of 3 years
109	following the current contract expiration date, regardless of
110	any contractual provisions to the contrary. A provider service
111	network is a network established or organized and operated by a
112	health care provider, or group of affiliated health care
113	providers, including minority physician networks and emergency
114	room diversion programs that meet the requirements of s.
115	409.91211, which provides a substantial proportion of the health
116	care items and services under a contract directly through the
117	provider or affiliated group of providers and may make
118	arrangements with physicians or other health care professionals,
119	health care institutions, or any combination of such individuals
120	or institutions to assume all or part of the financial risk on a
121	prospective basis for the provision of basic health services by
122	the physicians, by other health professionals, or through the
123	institutions. The health care providers must have a controlling
124	interest in the governing body of the provider service network
125	organization.
126	2.  The agency shall seek applications for and is
127	authorized to contract with a specialty provider service network
128	that exclusively enrolls Medicaid beneficiaries who have
129	psychiatric disabilities. For purposes of this section,
130	"psychiatric disability" includes schizophrenia, schizoaffective
131	disorder, major depression, bipolar disorder, manic and
132	depressive disorders, delusional disorders, psychosis, conduct
133	disorder and other emotional disturbances, attention deficit
134	hyperactivity disorder, panic disorder, and obsessive-compulsive
135	disorder or any person who, during the past year, has met at
136	least one of the following severity criteria: inpatient
137	psychiatric hospitalization or use of antipsychotic medications.
138	The Medicaid specialty provider service network shall provide
139	the full range of physical and behavioral health services that
140	other Medicaid health maintenance organizations and provider
141	service networks are required to provide. Medicaid beneficiaries
142	having psychiatric disabilities who are required but fail to
143	select a managed care plan shall be assigned to the specialty
144	provider service network in those geographic areas where a
145	specialty provider service network is available. For purposes of
146	enrollment, in addition to beneficiaries who meet the diagnostic
147	criteria indicating a mental illness or emotional disturbance,
148	beneficiaries served by Medicaid-enrolled community mental
149	health agencies or who voluntarily choose the specialty provider
150	service network shall be presumed to meet the plan enrollment
151	criteria. The agency is not required to complete an assessment
152	to determine the eligibility of beneficiaries for enrollment in
153	a specialty provider service network. For current beneficiaries
154	with a claims history, a determination shall be based on current
155	Medicaid data. New beneficiaries without a claims history who
156	have not made a choice are not eligible for assignment to a
157	specialty provider service network. However, during the open
158	enrollment period when beneficiaries may change their plan, a
159	beneficiary's request to be assigned to a specialty provider
160	service network is sufficient for the agency to determine that
161	the beneficiary qualifies for the specialty provider service
162	network.
163	Section 2.  Paragraphs (o) and (aa) of subsection (3) and
164	paragraphs (a), (b), (c), (d), and (e) of subsection (4) of
165	section 409.91211, Florida Statutes, are amended, and paragraph
166	(ee) is added to subsection (3) of that section, to read:
167	409.91211  Medicaid managed care pilot program.--
168	(3)  The agency shall have the following powers, duties,
169	and responsibilities with respect to the pilot program:
170	(o)  To implement eligibility assignment processes to
171	facilitate client choice while ensuring pilot programs of
172	adequate enrollment levels. These processes shall ensure that
173	pilot sites have sufficient levels of enrollment to conduct a
174	valid test of the managed care pilot program within a 2-year
175	timeframe. The eligibility assignment process shall be modified
176	as specified in paragraph (aa).
177	(aa)  To implement a mechanism whereby Medicaid recipients
178	who are already enrolled in a managed care plan or the MediPass
179	program in the pilot areas shall be offered the opportunity to
180	change to capitated managed care plans on a staggered basis, as
181	defined by the agency. All Medicaid recipients shall have 30
182	days in which to make a choice of capitated managed care plans.
183	Those Medicaid recipients who do not make a choice shall be
184	assigned to a capitated managed care plan in accordance with
185	paragraph (4)(a) and shall be exempt from s. 409.9122. To
186	facilitate continuity of care for a Medicaid recipient who is
187	also a recipient of Supplemental Security Income (SSI), prior to
188	assigning the SSI recipient to a capitated managed care plan,
189	the agency shall determine whether the SSI recipient has an
190	ongoing relationship with a provider, including a community
191	mental health provider or capitated managed care plan, and, if
192	so, the agency shall assign the SSI recipient to that provider
193	or capitated managed care plan where feasible. Those SSI
194	recipients who do not have such a provider relationship shall be
195	assigned to a capitated managed care plan provider in accordance
196	with this paragraph and paragraphs (4)(a)-(d) and shall be
197	exempt from s. 409.9122.
198	(ee)  To develop and implement a service delivery
199	alternative within capitated managed care plans to provide
200	Medicaid services as specified in ss. 409.905 and 409.906 for
201	persons who have psychiatric disabilities, which are sufficient
202	to meet the medical, developmental, and emotional needs of those
203	persons.
204	(4)(a)  A Medicaid recipient in the pilot area who is not
205	currently enrolled in a capitated managed care plan upon
206	implementation is not eligible for services as specified in ss.
207	409.905 and 409.906, for the amount of time that the recipient
208	does not enroll in a capitated managed care network. If a
209	Medicaid recipient has not enrolled in a capitated managed care
210	plan within 30 days after eligibility, the agency shall assign
211	the Medicaid recipient to a capitated managed care plan based on
212	the assessed needs of the recipient as determined by the agency
213	and the recipient shall be exempt from s. 409.9122. When making
214	assignments, the agency shall take into account the following
215	criteria:
216	1.  A capitated managed care network has sufficient network
217	capacity to meet the needs of members.
218	2.  The capitated managed care network has previously
219	enrolled the recipient as a member, or one of the capitated
220	managed care network's primary care providers has previously
221	provided health care to the recipient.
222	3.  The agency has knowledge that the member has previously
223	expressed a preference for a particular capitated managed care
224	network as indicated by Medicaid fee-for-service claims data,
225	but has failed to make a choice.
226	4.  The capitated managed care network's primary care
227	providers are geographically accessible to the recipient's
228	residence.
229	5.  The extent of the psychiatric disability of the
230	Medicaid beneficiary.
231	(b)  When more than one capitated managed care network
232	provider meets the criteria specified in paragraph (3)(h), the
233	agency shall assess a beneficiary's psychiatric disability
234	before making an assignment and make recipient assignments
235	consecutively by family unit.
236	(c)  If a recipient is currently enrolled with a Medicaid
237	managed care organization that also operates an approved reform
238	plan within a demonstration area and the recipient fails to
239	choose a plan during the reform enrollment process or during
240	redetermination of eligibility, the recipient shall be
241	automatically assigned by the agency into the most appropriate
242	reform plan operated by the recipient's current Medicaid managed
243	care plan. If the recipient's current managed care plan does not
244	operate a reform plan in the demonstration area which adequately
245	meets the needs of the Medicaid recipient, the agency shall use
246	the automatic assignment process as prescribed in the special
247	terms and conditions numbered 11-W-00206/4. All enrollment and
248	choice counseling materials provided by the agency must contain
249	an explanation of the provisions of this paragraph for current
250	managed care recipients and an explanation of the choice of any
251	specialty provider service network or specialty managed care
252	plan.
253	(d)  Except as provided in paragraph (b), the agency may
254	not engage in practices that are designed to favor one capitated
255	managed care plan over another or that are designed to influence
256	Medicaid recipients to enroll in a particular capitated managed
257	care network in order to strengthen its particular fiscal
258	viability.
259	(e)  After a recipient has made a selection or has been
260	enrolled in a capitated managed care network, the recipient
261	shall have 90 days in which to voluntarily disenroll and select
262	another capitated managed care network. After 90 days, no
263	further changes may be made except for cause. Cause shall
264	include, but not be limited to, poor quality of care, lack of
265	access to necessary specialty services, an unreasonable delay or
266	denial of service, inordinate or inappropriate changes of
267	primary care providers, service access impairments due to
268	significant changes in the geographic location of services, or
269	fraudulent enrollment. The agency may require a recipient to use
270	the capitated managed care network's grievance process as
271	specified in paragraph (3)(q) prior to the agency's
272	determination of cause, except in cases in which immediate risk
273	of permanent damage to the recipient's health is alleged. The
274	grievance process, when used, must be completed in time to
275	permit the recipient to disenroll no later than the first day of
276	the second month after the month the disenrollment request was
277	made. If the capitated managed care network, as a result of the
278	grievance process, approves an enrollee's request to disenroll,
279	the agency is not required to make a determination in the case.
280	The agency must make a determination and take final action on a
281	recipient's request so that disenrollment occurs no later than
282	the first day of the second month after the month the request
283	was made. If the agency fails to act within the specified
284	timeframe, the recipient's request to disenroll is deemed to be
285	approved as of the date agency action was required. Recipients
286	who disagree with the agency's finding that cause does not exist
287	for disenrollment shall be advised of their right to pursue a
288	Medicaid fair hearing to dispute the agency's finding. When a
289	specialty provider service network or a specialty managed care
290	plan first becomes available in a geographic area, beneficiaries
291	meeting diagnostic criteria shall be offered an open enrollment
292	period during which they may choose to reenroll in a specialty
293	provider service network or specialty managed care plan.
294	Section 3.  This act shall take effect July 1, 2008.

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