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	providing an exception from applicability; amending s.
14	409.91211, F.S.; requiring that the agency modify
15	eligibility assignment processes for managed care pilot
16	programs to include specialty plans that specialize in
17	care for beneficiaries who have psychiatric disabilities;
18	requiring the agency to provide a service delivery
19	alternative to provide Medicaid services to persons having
20	psychiatric disabilities; providing an additional
21	criterion for the agency in making assignments; requiring
22	that enrollment and choice counseling materials contain an
23	explanation concerning the choice of a network or plan;
24	providing for an additional open enrollment period
25	following the availability of specialty services;
26	providing an effective date.
27
28	Be It Enacted by the Legislature of the State of Florida:
29
30	Section 1.  Paragraph (d) of subsection (4) of section
31	409.912, Florida Statutes, is amended to read:
32	409.912  Cost-effective purchasing of health care.--The
33	agency shall purchase goods and services for Medicaid recipients
34	in the most cost-effective manner consistent with the delivery
35	of quality medical care. To ensure that medical services are
36	effectively utilized, the agency may, in any case, require a
37	confirmation or second physician's opinion of the correct
38	diagnosis for purposes of authorizing future services under the
39	Medicaid program. This section does not restrict access to
40	emergency services or poststabilization care services as defined
41	in 42 C.F.R. part 438.114. Such confirmation or second opinion
42	shall be rendered in a manner approved by the agency. The agency
43	shall maximize the use of prepaid per capita and prepaid
44	aggregate fixed-sum basis services when appropriate and other
45	alternative service delivery and reimbursement methodologies,
46	including competitive bidding pursuant to s. 287.057, designed
47	to facilitate the cost-effective purchase of a case-managed
48	continuum of care. The agency shall also require providers to
49	minimize the exposure of recipients to the need for acute
50	inpatient, custodial, and other institutional care and the
51	inappropriate or unnecessary use of high-cost services. The
52	agency shall contract with a vendor to monitor and evaluate the
53	clinical practice patterns of providers in order to identify
54	trends that are outside the normal practice patterns of a
55	provider's professional peers or the national guidelines of a
56	provider's professional association. The vendor must be able to
57	provide information and counseling to a provider whose practice
58	patterns are outside the norms, in consultation with the agency,
59	to improve patient care and reduce inappropriate utilization.
60	The agency may mandate prior authorization, drug therapy
61	management, or disease management participation for certain
62	populations of Medicaid beneficiaries, certain drug classes, or
63	particular drugs to prevent fraud, abuse, overuse, and possible
64	dangerous drug interactions. The Pharmaceutical and Therapeutics
65	Committee shall make recommendations to the agency on drugs for
66	which prior authorization is required. The agency shall inform
67	the Pharmaceutical and Therapeutics Committee of its decisions
68	regarding drugs subject to prior authorization. The agency is
69	authorized to limit the entities it contracts with or enrolls as
70	Medicaid providers by developing a provider network through
71	provider credentialing. The agency may competitively bid single-
72	source-provider contracts if procurement of goods or services
73	results in demonstrated cost savings to the state without
74	limiting access to care. The agency may limit its network based
75	on the assessment of beneficiary access to care, provider
76	availability, provider quality standards, time and distance
77	standards for access to care, the cultural competence of the
78	provider network, demographic characteristics of Medicaid
79	beneficiaries, practice and provider-to-beneficiary standards,
80	appointment wait times, beneficiary use of services, provider
81	turnover, provider profiling, provider licensure history,
82	previous program integrity investigations and findings, peer
83	review, provider Medicaid policy and billing compliance records,
84	clinical and medical record audits, and other factors. Providers
85	shall not be entitled to enrollment in the Medicaid provider
86	network. The agency shall determine instances in which allowing
87	Medicaid beneficiaries to purchase durable medical equipment and
88	other goods is less expensive to the Medicaid program than long-
89	term rental of the equipment or goods. The agency may establish
90	rules to facilitate purchases in lieu of long-term rentals in
91	order to protect against fraud and abuse in the Medicaid program
92	as defined in s. 409.913. The agency may seek federal waivers
93	necessary to administer these policies.
94	(4)  The agency may contract with:
95	(d)  A provider service network, which may be reimbursed on
96	a fee-for-service or prepaid basis. A provider service network
97	that which is reimbursed by the agency on a prepaid basis is
98	shall be exempt from parts I and III of chapter 641, but must
99	comply with the solvency requirements in s. 641.2261(2) and meet
100	appropriate financial reserve, quality assurance, and patient
101	rights requirements as established by the agency.
102	1.  Except as provided in subparagraph 2., Medicaid
103	recipients assigned to a provider service network shall be
104	chosen equally from those who would otherwise have been assigned
105	to prepaid plans and MediPass. The agency is authorized to seek
106	federal Medicaid waivers as necessary to implement the
107	provisions of this section. Any contract previously awarded to a
108	provider service network operated by a hospital pursuant to this
109	subsection shall remain in effect for a period of 3 years
110	following the current contract expiration date, regardless of
111	any contractual provisions to the contrary. A provider service
112	network is a network established or organized and operated by a
113	health care provider, or group of affiliated health care
114	providers, including minority physician networks and emergency
115	room diversion programs that meet the requirements of s.
116	409.91211, which provides a substantial proportion of the health
117	care items and services under a contract directly through the
118	provider or affiliated group of providers and may make
119	arrangements with physicians or other health care professionals,
120	health care institutions, or any combination of such individuals
121	or institutions to assume all or part of the financial risk on a
122	prospective basis for the provision of basic health services by
123	the physicians, by other health professionals, or through the
124	institutions. The health care providers must have a controlling
125	interest in the governing body of the provider service network
126	organization.
127	2.  For the purpose of demonstrating the cost-effectiveness
128	of the provision of quality mental health services for the
129	population defined in this section, AHCA area 11 shall be
130	designated a pilot area and the agency shall seek applications
131	and is authorized to contract with a specialty provider service
132	network in that area that exclusively enrolls Medicaid
133	beneficiaries who have psychiatric disabilities. For purposes of
134	this section, "psychiatric disability" includes schizophrenia,
135	schizoaffective disorder, major depression, bipolar disorder,
136	manic and depressive disorders, delusional disorders, psychosis,
137	conduct disorder and other emotional disturbances, attention
138	deficit hyperactivity disorder, panic disorder, and obsessive-
139	compulsive disorder or any person who, during the past year, has
140	met at least one of the following severity criteria: inpatient
141	psychiatric hospitalization or use of antipsychotic medications.
142	The Medicaid specialty provider service network shall provide
143	the full range of physical and behavioral health services that
144	other Medicaid health maintenance organizations and provider
145	service networks are required to provide. Medicaid beneficiaries
146	having psychiatric disabilities who are required but fail to
147	select a managed care plan shall be assigned to the specialty
148	provider service network in those geographic areas where a
149	specialty provider service network is available. For purposes of
150	enrollment, in addition to beneficiaries who meet the diagnostic
151	criteria indicating a mental illness or emotional disturbance,
152	beneficiaries served by Medicaid-enrolled community mental
153	health agencies or who voluntarily choose the specialty provider
154	service network shall be presumed to meet the plan enrollment
155	criteria. The agency is not required to complete an assessment
156	to determine the eligibility of beneficiaries for enrollment in
157	a specialty provider service network. For current beneficiaries
158	with a claims history, a determination shall be based on current
159	Medicaid data. New beneficiaries without a claims history who
160	have not made a choice are not eligible for assignment to a
161	specialty provider service network. However, during the open
162	enrollment period when beneficiaries may change their plan, a
163	beneficiary's request to be assigned to a specialty provider
164	service network is sufficient for the agency to determine that
165	the beneficiary qualifies for the specialty provider service
166	network. However, the provisions of this subparagraph shall not
167	apply to the existing provider service network operated by the
168	public hospital in AHCA Area 11.
169	Section 2.  Paragraphs (o) and (aa) of subsection (3) and
170	paragraphs (a), (b), (c), (d), and (e) of subsection (4) of
171	section 409.91211, Florida Statutes, are amended, and paragraph
172	(ee) is added to subsection (3) of that section, to read:
173	409.91211  Medicaid managed care pilot program.--
174	(3)  The agency shall have the following powers, duties,
175	and responsibilities with respect to the pilot program:
176	(o)  To implement eligibility assignment processes to
177	facilitate client choice while ensuring pilot programs of
178	adequate enrollment levels. These processes shall ensure that
179	pilot sites have sufficient levels of enrollment to conduct a
180	valid test of the managed care pilot program within a 2-year
181	timeframe. The eligibility assignment process shall be modified
182	as specified in paragraph (aa).
183	(aa)  To implement a mechanism whereby Medicaid recipients
184	who are already enrolled in a managed care plan or the MediPass
185	program in the pilot areas shall be offered the opportunity to
186	change to capitated managed care plans on a staggered basis, as
187	defined by the agency. All Medicaid recipients shall have 30
188	days in which to make a choice of capitated managed care plans.
189	Those Medicaid recipients who do not make a choice shall be
190	assigned to a capitated managed care plan in accordance with
191	paragraph (4)(a) and shall be exempt from s. 409.9122. To
192	facilitate continuity of care for a Medicaid recipient who is
193	also a recipient of Supplemental Security Income (SSI), prior to
194	assigning the SSI recipient to a capitated managed care plan,
195	the agency shall determine whether the SSI recipient has an
196	ongoing relationship with a provider, including a community
197	mental health provider or capitated managed care plan, and, if
198	so, the agency shall assign the SSI recipient to that provider
199	or capitated managed care plan where feasible. Those SSI
200	recipients who do not have such a provider relationship shall be
201	assigned to a capitated managed care plan provider in accordance
202	with this paragraph and paragraphs (4)(a)-(d) and shall be
203	exempt from s. 409.9122.
204	(ee)  To develop and implement a service delivery
205	alternative within capitated managed care plans to provide
206	Medicaid services as specified in ss. 409.905 and 409.906 for
207	persons who have psychiatric disabilities, which are sufficient
208	to meet the medical, developmental, and emotional needs of those
209	persons.
210	(4)(a)  A Medicaid recipient in the pilot area who is not
211	currently enrolled in a capitated managed care plan upon
212	implementation is not eligible for services as specified in ss.
213	409.905 and 409.906, for the amount of time that the recipient
214	does not enroll in a capitated managed care network. If a
215	Medicaid recipient has not enrolled in a capitated managed care
216	plan within 30 days after eligibility, the agency shall assign
217	the Medicaid recipient to a capitated managed care plan based on
218	the assessed needs of the recipient as determined by the agency
219	and the recipient shall be exempt from s. 409.9122. When making
220	assignments, the agency shall take into account the following
221	criteria:
222	1.  A capitated managed care network has sufficient network
223	capacity to meet the needs of members.
224	2.  The capitated managed care network has previously
225	enrolled the recipient as a member, or one of the capitated
226	managed care network's primary care providers has previously
227	provided health care to the recipient.
228	3.  The agency has knowledge that the member has previously
229	expressed a preference for a particular capitated managed care
230	network as indicated by Medicaid fee-for-service claims data,
231	but has failed to make a choice.
232	4.  The capitated managed care network's primary care
233	providers are geographically accessible to the recipient's
234	residence.
235	5.  The extent of the psychiatric disability of the
236	Medicaid beneficiary.
237	(b)  When more than one capitated managed care network
238	provider meets the criteria specified in paragraph (3)(h), the
239	agency shall assess a beneficiary's psychiatric disability
240	before making an assignment and make recipient assignments
241	consecutively by family unit.
242	(c)  If a recipient is currently enrolled with a Medicaid
243	managed care organization that also operates an approved reform
244	plan within a demonstration area and the recipient fails to
245	choose a plan during the reform enrollment process or during
246	redetermination of eligibility, the recipient shall be
247	automatically assigned by the agency into the most appropriate
248	reform plan operated by the recipient's current Medicaid managed
249	care plan. If the recipient's current managed care plan does not
250	operate a reform plan in the demonstration area which adequately
251	meets the needs of the Medicaid recipient, the agency shall use
252	the automatic assignment process as prescribed in the special
253	terms and conditions numbered 11-W-00206/4. All enrollment and
254	choice counseling materials provided by the agency must contain
255	an explanation of the provisions of this paragraph for current
256	managed care recipients and an explanation of the choice of any
257	specialty provider service network or specialty managed care
258	plan.
259	(d)  Except as provided in paragraph (b), the agency may
260	not engage in practices that are designed to favor one capitated
261	managed care plan over another or that are designed to influence
262	Medicaid recipients to enroll in a particular capitated managed
263	care network in order to strengthen its particular fiscal
264	viability.
265	(e)  After a recipient has made a selection or has been
266	enrolled in a capitated managed care network, the recipient
267	shall have 90 days in which to voluntarily disenroll and select
268	another capitated managed care network. After 90 days, no
269	further changes may be made except for cause. Cause shall
270	include, but not be limited to, poor quality of care, lack of
271	access to necessary specialty services, an unreasonable delay or
272	denial of service, inordinate or inappropriate changes of
273	primary care providers, service access impairments due to
274	significant changes in the geographic location of services, or
275	fraudulent enrollment. The agency may require a recipient to use
276	the capitated managed care network's grievance process as
277	specified in paragraph (3)(q) prior to the agency's
278	determination of cause, except in cases in which immediate risk
279	of permanent damage to the recipient's health is alleged. The
280	grievance process, when used, must be completed in time to
281	permit the recipient to disenroll no later than the first day of
282	the second month after the month the disenrollment request was
283	made. If the capitated managed care network, as a result of the
284	grievance process, approves an enrollee's request to disenroll,
285	the agency is not required to make a determination in the case.
286	The agency must make a determination and take final action on a
287	recipient's request so that disenrollment occurs no later than
288	the first day of the second month after the month the request
289	was made. If the agency fails to act within the specified
290	timeframe, the recipient's request to disenroll is deemed to be
291	approved as of the date agency action was required. Recipients
292	who disagree with the agency's finding that cause does not exist
293	for disenrollment shall be advised of their right to pursue a
294	Medicaid fair hearing to dispute the agency's finding. When a
295	specialty provider service network or a specialty managed care
296	plan first becomes available in a geographic area, beneficiaries
297	meeting diagnostic criteria shall be offered an open enrollment
298	period during which they may choose to reenroll in a specialty
299	provider service network or specialty managed care plan.
300	Section 3.  This act shall take effect July 1, 2008.

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