Florida Senate - 2008 (Reformatted) SB 846
By Senator Rich
34-02572A-08 2008846__
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A bill to be entitled
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An act relating to Medicaid provider service networks;
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amending s. 409.912, F.S.; authorizing the Agency for
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Health Care Administration to contract with a specialty
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provider service network that exclusively enrolls Medicaid
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beneficiaries who have psychiatric disabilities; requiring
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the specialty provider to offer the same physical and
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behavioral health services that are required from other
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Medicaid health maintenance organizations and provider
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service networks; requiring that beneficiaries be assigned
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to a specialty provider service network under certain
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circumstances; amending s. 409.91211, F.S.; requiring that
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the agency modify eligibility assignment processes for
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managed care pilot programs to include specialty plans
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that specialize in care for beneficiaries who have
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psychiatric disabilities; requiring the agency to provide
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a service delivery alternative to provide Medicaid
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services to persons having psychiatric disabilities;
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providing an additional criterion for the agency in making
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assignments; requiring that enrollment and choice
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counseling materials contain an explanation concerning the
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choice of a network or plan; providing for an additional
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open enrollment period following the availability of
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specialty services; providing an effective date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Paragraph (d) of subsection (4) of section
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409.912, Florida Statutes, is amended to read:
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409.912 Cost-effective purchasing of health care.--The
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agency shall purchase goods and services for Medicaid recipients
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in the most cost-effective manner consistent with the delivery of
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quality medical care. To ensure that medical services are
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effectively utilized, the agency may, in any case, require a
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confirmation or second physician's opinion of the correct
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diagnosis for purposes of authorizing future services under the
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Medicaid program. This section does not restrict access to
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emergency services or poststabilization care services as defined
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in 42 C.F.R. part 438.114. Such confirmation or second opinion
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shall be rendered in a manner approved by the agency. The agency
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shall maximize the use of prepaid per capita and prepaid
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aggregate fixed-sum basis services when appropriate and other
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alternative service delivery and reimbursement methodologies,
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including competitive bidding pursuant to s. 287.057, designed to
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facilitate the cost-effective purchase of a case-managed
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continuum of care. The agency shall also require providers to
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minimize the exposure of recipients to the need for acute
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inpatient, custodial, and other institutional care and the
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inappropriate or unnecessary use of high-cost services. The
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agency shall contract with a vendor to monitor and evaluate the
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clinical practice patterns of providers in order to identify
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trends that are outside the normal practice patterns of a
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provider's professional peers or the national guidelines of a
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provider's professional association. The vendor must be able to
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provide information and counseling to a provider whose practice
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patterns are outside the norms, in consultation with the agency,
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to improve patient care and reduce inappropriate utilization. The
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agency may mandate prior authorization, drug therapy management,
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or disease management participation for certain populations of
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Medicaid beneficiaries, certain drug classes, or particular drugs
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to prevent fraud, abuse, overuse, and possible dangerous drug
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interactions. The Pharmaceutical and Therapeutics Committee shall
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make recommendations to the agency on drugs for which prior
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authorization is required. The agency shall inform the
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Pharmaceutical and Therapeutics Committee of its decisions
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regarding drugs subject to prior authorization. The agency is
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authorized to limit the entities it contracts with or enrolls as
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Medicaid providers by developing a provider network through
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provider credentialing. The agency may competitively bid single-
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source-provider contracts if procurement of goods or services
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results in demonstrated cost savings to the state without
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limiting access to care. The agency may limit its network based
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on the assessment of beneficiary access to care, provider
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availability, provider quality standards, time and distance
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standards for access to care, the cultural competence of the
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provider network, demographic characteristics of Medicaid
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beneficiaries, practice and provider-to-beneficiary standards,
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appointment wait times, beneficiary use of services, provider
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turnover, provider profiling, provider licensure history,
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previous program integrity investigations and findings, peer
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review, provider Medicaid policy and billing compliance records,
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clinical and medical record audits, and other factors. Providers
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shall not be entitled to enrollment in the Medicaid provider
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network. The agency shall determine instances in which allowing
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Medicaid beneficiaries to purchase durable medical equipment and
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other goods is less expensive to the Medicaid program than long-
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term rental of the equipment or goods. The agency may establish
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rules to facilitate purchases in lieu of long-term rentals in
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order to protect against fraud and abuse in the Medicaid program
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as defined in s. 409.913. The agency may seek federal waivers
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necessary to administer these policies.
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(4) The agency may contract with:
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(d) A provider service network, which may be reimbursed on
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a fee-for-service or prepaid basis. A provider service network
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that which is reimbursed by the agency on a prepaid basis is
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shall be exempt from parts I and III of chapter 641, but must
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comply with the solvency requirements in s. 641.2261(2) and meet
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appropriate financial reserve, quality assurance, and patient
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rights requirements as established by the agency.
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1. Except as provided in subparagraph 2., Medicaid
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recipients assigned to a provider service network shall be chosen
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equally from those who would otherwise have been assigned to
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prepaid plans and MediPass. The agency is authorized to seek
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federal Medicaid waivers as necessary to implement the provisions
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of this section. Any contract previously awarded to a provider
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service network operated by a hospital pursuant to this
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subsection shall remain in effect for a period of 3 years
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following the current contract expiration date, regardless of any
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contractual provisions to the contrary. A provider service
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network is a network established or organized and operated by a
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health care provider, or group of affiliated health care
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providers, including minority physician networks and emergency
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room diversion programs that meet the requirements of s.
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409.91211, which provides a substantial proportion of the health
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care items and services under a contract directly through the
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provider or affiliated group of providers and may make
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arrangements with physicians or other health care professionals,
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health care institutions, or any combination of such individuals
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or institutions to assume all or part of the financial risk on a
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prospective basis for the provision of basic health services by
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the physicians, by other health professionals, or through the
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institutions. The health care providers must have a controlling
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interest in the governing body of the provider service network
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organization.
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2. The agency shall seek applications for and is authorized
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to contract with a specialty provider service network that
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exclusively enrolls Medicaid beneficiaries who have psychiatric
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disabilities. The Medicaid specialty provider service network
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shall be responsible for providing the full range of physical and
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behavioral health services that other Medicaid health maintenance
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organizations and provider service networks are required to
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provide. Medicaid beneficiaries having psychiatric disabilities
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who are required but fail to select a managed care plan shall be
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assigned to the specialty provider service network in those
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geographic areas where a specialty provider service network is
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available. For purposes of enrollment, in addition to those who
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meet the diagnostic criteria indicating a mental illness or
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emotional disturbance, beneficiaries served by Medicaid-enrolled
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community mental health agencies or who voluntarily choose the
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specialty provider service network shall be presumed to meet the
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plan enrollment criteria.
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Section 2. Paragraphs (o) and (aa) of subsection (3) and
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paragraphs (a), (b), (c), (d), and (e) of subsection (4) of
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section 409.91211, Florida Statutes, are amended, and paragraph
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(ee) is added to subsection (3) of that section, to read:
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409.91211 Medicaid managed care pilot program.--
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(3) The agency shall have the following powers, duties, and
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responsibilities with respect to the pilot program:
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(o) To implement eligibility assignment processes to
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facilitate client choice while ensuring pilot programs of
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adequate enrollment levels. These processes shall ensure that
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pilot sites have sufficient levels of enrollment to conduct a
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valid test of the managed care pilot program within a 2-year
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timeframe. The eligibility assignment process shall be modified
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as specified in paragraph (aa).
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(aa) To implement a mechanism whereby Medicaid recipients
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who are already enrolled in a managed care plan or the MediPass
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program in the pilot areas shall be offered the opportunity to
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change to capitated managed care plans on a staggered basis, as
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defined by the agency. All Medicaid recipients shall have 30 days
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in which to make a choice of capitated managed care plans. Those
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Medicaid recipients who do not make a choice shall be assigned to
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a capitated managed care plan in accordance with paragraph (4)(a)
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and shall be exempt from s. 409.9122. To facilitate continuity of
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care for a Medicaid recipient who is also a recipient of
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Supplemental Security Income (SSI), prior to assigning the SSI
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recipient to a capitated managed care plan, the agency shall
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determine whether the SSI recipient has an ongoing relationship
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with a provider, including a community mental health provider or
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capitated managed care plan, and, if so, the agency shall assign
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the SSI recipient to that provider, provider service network, or
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capitated managed care plan where feasible. Those SSI recipients
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who do not have such a provider relationship shall be assigned to
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a capitated managed care plan provider in accordance with this
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paragraph and paragraphs (4)(a) through (d) and shall be exempt
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from s. 409.9122.
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(ee) To develop and implement a service delivery
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alternative within capitated managed care plans to provide
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persons who have psychiatric disabilities which are sufficient to
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meet the medical, developmental, and emotional needs of those
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persons.
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(4)(a) A Medicaid recipient in the pilot area who is not
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currently enrolled in a capitated managed care plan upon
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implementation is not eligible for services as specified in ss.
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does not enroll in a capitated managed care network. If a
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Medicaid recipient has not enrolled in a capitated managed care
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plan within 30 days after eligibility, the agency shall assign
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the Medicaid recipient to a capitated managed care plan based on
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the assessed needs of the recipient as determined by the agency
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and the recipient shall be exempt from s. 409.9122. When making
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assignments, the agency shall take into account the following
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criteria:
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1. A capitated managed care network has sufficient network
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capacity to meet the needs of members.
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2. The capitated managed care network has previously
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enrolled the recipient as a member, or one of the capitated
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managed care network's primary care providers has previously
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provided health care to the recipient.
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3. The agency has knowledge that the member has previously
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expressed a preference for a particular capitated managed care
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network as indicated by Medicaid fee-for-service claims data, but
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has failed to make a choice.
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4. The capitated managed care network's primary care
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providers are geographically accessible to the recipient's
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residence.
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5. The extent of the psychiatric disability of the Medicaid
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beneficiary.
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(b) When more than one capitated managed care network
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provider meets the criteria specified in paragraph (3)(h), the
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agency shall assess a beneficiary's psychiatric disability before
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making an assignment and make recipient assignments consecutively
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by family unit.
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(c) If a recipient is currently enrolled with a Medicaid
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managed care organization that also operates an approved reform
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plan within a demonstration area and the recipient fails to
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choose a plan during the reform enrollment process or during
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redetermination of eligibility, the recipient shall be
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automatically assigned by the agency into the most appropriate
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reform plan operated by the recipient's current Medicaid managed
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care plan. If the recipient's current managed care plan does not
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operate a reform plan in the demonstration area which adequately
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meets the needs of the Medicaid recipient, the agency shall use
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the automatic assignment process as prescribed in the special
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terms and conditions numbered 11-W-00206/4. All enrollment and
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choice counseling materials provided by the agency must contain
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an explanation of the provisions of this paragraph for current
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managed care recipients and an explanation of the choice of any
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specialty provider service network or specialty managed care
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plan.
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(d) Except as provided in paragraph (b), the agency may not
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engage in practices that are designed to favor one capitated
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managed care plan over another or that are designed to influence
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Medicaid recipients to enroll in a particular capitated managed
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care network in order to strengthen its particular fiscal
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viability.
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(e) After a recipient has made a selection or has been
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enrolled in a capitated managed care network, the recipient shall
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have 90 days in which to voluntarily disenroll and select another
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capitated managed care network. After 90 days, no further changes
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may be made except for cause. Cause shall include, but not be
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limited to, poor quality of care, lack of access to necessary
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specialty services, an unreasonable delay or denial of service,
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inordinate or inappropriate changes of primary care providers,
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service access impairments due to significant changes in the
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geographic location of services, or fraudulent enrollment. The
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agency may require a recipient to use the capitated managed care
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network's grievance process as specified in paragraph (3)(q)
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prior to the agency's determination of cause, except in cases in
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which immediate risk of permanent damage to the recipient's
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health is alleged. The grievance process, when used, must be
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completed in time to permit the recipient to disenroll no later
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than the first day of the second month after the month the
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disenrollment request was made. If the capitated managed care
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network, as a result of the grievance process, approves an
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enrollee's request to disenroll, the agency is not required to
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make a determination in the case. The agency must make a
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determination and take final action on a recipient's request so
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that disenrollment occurs no later than the first day of the
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second month after the month the request was made. If the agency
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fails to act within the specified timeframe, the recipient's
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request to disenroll is deemed to be approved as of the date
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agency action was required. Recipients who disagree with the
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agency's finding that cause does not exist for disenrollment
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shall be advised of their right to pursue a Medicaid fair hearing
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to dispute the agency's finding. When a specialty provider
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service network or specialty managed care plan first becomes
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available in a geographic area, beneficiaries meeting diagnostic
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criteria shall be offered an open enrollment period during which
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they may choose to reenroll in a specialty provider service
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network or specialty managed care plan.
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Section 3. This act shall take effect July 1, 2008.
CODING: Words stricken are deletions; words underlined are additions.