Florida Senate - 2008 CS for SB 846
By the Committee on Children, Families, and Elder Affairs; and Senators Rich, Dean, Dawson, Dockery and Lynn
586-06456-08 2008846c1
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 of
34
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 to
46
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. The
59
agency may mandate prior authorization, drug therapy management,
60
or disease management participation for certain populations of
61
Medicaid beneficiaries, certain drug classes, or particular drugs
62
to prevent fraud, abuse, overuse, and possible dangerous drug
63
interactions. The Pharmaceutical and Therapeutics Committee shall
64
make recommendations to the agency on drugs for which prior
65
authorization is required. The agency shall inform the
66
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 chosen
103
equally from those who would otherwise have been assigned to
104
prepaid plans and MediPass. The agency is authorized to seek
105
federal Medicaid waivers as necessary to implement the provisions
106
of this section. Any contract previously awarded to a provider
107
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 any
110
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 authorized
127
to contract with a specialty provider service network that
128
exclusively enrolls Medicaid beneficiaries who have psychiatric
129
disabilities. For purposes of this section, "psychiatric
130
disability" includes schizophrenia, schizoaffective disorder,
131
major depression, bipolar, manic and depressive disorders,
132
delusional disorders, psychosis, conduct disorders and other
133
emotional disturbances, attention deficit hyperactivity disorder,
134
panic disorders, and obsessive-compulsive disorders or any person
135
who, during the past year, has met at least one of the following
136
severity criteria: inpatient psychiatric hospitalization or use
137
of antipsychotic medications. The Medicaid specialty provider
138
service network shall provide the full range of physical and
139
behavioral health services that other Medicaid health maintenance
140
organizations and provider service networks are required to
141
provide. Medicaid beneficiaries having psychiatric disabilities
142
who are required but fail to select a managed care plan shall be
143
assigned to the specialty provider service network in those
144
geographic areas where a specialty provider service network is
145
available. For purposes of enrollment, in addition to those who
146
meet the diagnostic criteria indicating a mental illness or
147
emotional disturbance, beneficiaries served by Medicaid-enrolled
148
community mental health agencies or who voluntarily choose the
149
specialty provider service network shall be presumed to meet the
150
plan enrollment criteria. The agency is not required to complete
151
an assessment to determine the eligibility of beneficiaries for
152
enrollment in a specialty provider service network. For current
153
beneficiaries with a claims history, a determination shall be
154
based on current Medicaid data. New beneficiaries without a
155
claims history who have not made a choice are not eligible for
156
assignment to a specialty provider service network. However,
157
during the open enrollment period when beneficiaries can change
158
their plan, a beneficiary's request to be assigned to a specialty
159
provider service network is sufficient for the agency to
160
determine that the beneficiary qualifies for the specialty
161
provider service network.
162
Section 2. Paragraphs (o) and (aa) of subsection (3) and
163
paragraphs (a), (b), (c), (d), and (e) of subsection (4) of
164
section 409.91211, Florida Statutes, are amended, and paragraph
165
(ee) is added to subsection (3) of that section, to read:
166
409.91211 Medicaid managed care pilot program.--
167
(3) The agency shall have the following powers, duties, and
168
responsibilities with respect to the pilot program:
169
(o) To implement eligibility assignment processes to
170
facilitate client choice while ensuring pilot programs of
171
adequate enrollment levels. These processes shall ensure that
172
pilot sites have sufficient levels of enrollment to conduct a
173
valid test of the managed care pilot program within a 2-year
174
timeframe. The eligibility assignment process shall be modified
175
as specified in paragraph (aa).
176
(aa) To implement a mechanism whereby Medicaid recipients
177
who are already enrolled in a managed care plan or the MediPass
178
program in the pilot areas shall be offered the opportunity to
179
change to capitated managed care plans on a staggered basis, as
180
defined by the agency. All Medicaid recipients shall have 30 days
181
in which to make a choice of capitated managed care plans. Those
182
Medicaid recipients who do not make a choice shall be assigned to
183
a capitated managed care plan in accordance with paragraph (4)(a)
184
and shall be exempt from s. 409.9122. To facilitate continuity of
185
care for a Medicaid recipient who is also a recipient of
186
Supplemental Security Income (SSI), prior to assigning the SSI
187
recipient to a capitated managed care plan, the agency shall
188
determine whether the SSI recipient has an ongoing relationship
189
with a provider, including a community mental health provider or
190
capitated managed care plan, and, if so, the agency shall assign
191
the SSI recipient to that provider or capitated managed care plan
192
where feasible. Those SSI recipients who do not have such a
193
provider relationship shall be assigned to a capitated managed
194
care plan provider in accordance with this paragraph and
195
paragraphs (4)(a) through (d) and shall be exempt from s.
196
197
(ee) To develop and implement a service delivery
198
alternative within capitated managed care plans to provide
200
persons who have psychiatric disabilities, which are sufficient
201
to meet the medical, developmental, and emotional needs of those
202
persons.
203
(4)(a) A Medicaid recipient in the pilot area who is not
204
currently enrolled in a capitated managed care plan upon
205
implementation is not eligible for services as specified in ss.
207
does not enroll in a capitated managed care network. If a
208
Medicaid recipient has not enrolled in a capitated managed care
209
plan within 30 days after eligibility, the agency shall assign
210
the Medicaid recipient to a capitated managed care plan based on
211
the assessed needs of the recipient as determined by the agency
212
and the recipient shall be exempt from s. 409.9122. When making
213
assignments, the agency shall take into account the following
214
criteria:
215
1. A capitated managed care network has sufficient network
216
capacity to meet the needs of members.
217
2. The capitated managed care network has previously
218
enrolled the recipient as a member, or one of the capitated
219
managed care network's primary care providers has previously
220
provided health care to the recipient.
221
3. The agency has knowledge that the member has previously
222
expressed a preference for a particular capitated managed care
223
network as indicated by Medicaid fee-for-service claims data, but
224
has failed to make a choice.
225
4. The capitated managed care network's primary care
226
providers are geographically accessible to the recipient's
227
residence.
228
5. The extent of the psychiatric disability of the Medicaid
229
beneficiary.
230
(b) When more than one capitated managed care network
231
provider meets the criteria specified in paragraph (3)(h), the
232
agency shall assess a beneficiary's psychiatric disability before
233
making an assignment and make recipient assignments consecutively
234
by family unit.
235
(c) If a recipient is currently enrolled with a Medicaid
236
managed care organization that also operates an approved reform
237
plan within a demonstration area and the recipient fails to
238
choose a plan during the reform enrollment process or during
239
redetermination of eligibility, the recipient shall be
240
automatically assigned by the agency into the most appropriate
241
reform plan operated by the recipient's current Medicaid managed
242
care plan. If the recipient's current managed care plan does not
243
operate a reform plan in the demonstration area which adequately
244
meets the needs of the Medicaid recipient, the agency shall use
245
the automatic assignment process as prescribed in the special
246
terms and conditions numbered 11-W-00206/4. All enrollment and
247
choice counseling materials provided by the agency must contain
248
an explanation of the provisions of this paragraph for current
249
managed care recipients and an explanation of the choice of any
250
specialty provider service network or specialty managed care
251
plan.
252
(d) Except as provided in paragraph (b), the agency may not
253
engage in practices that are designed to favor one capitated
254
managed care plan over another or that are designed to influence
255
Medicaid recipients to enroll in a particular capitated managed
256
care network in order to strengthen its particular fiscal
257
viability.
258
(e) After a recipient has made a selection or has been
259
enrolled in a capitated managed care network, the recipient shall
260
have 90 days in which to voluntarily disenroll and select another
261
capitated managed care network. After 90 days, no further changes
262
may be made except for cause. Cause shall include, but not be
263
limited to, poor quality of care, lack of access to necessary
264
specialty services, an unreasonable delay or denial of service,
265
inordinate or inappropriate changes of primary care providers,
266
service access impairments due to significant changes in the
267
geographic location of services, or fraudulent enrollment. The
268
agency may require a recipient to use the capitated managed care
269
network's grievance process as specified in paragraph (3)(q)
270
prior to the agency's determination of cause, except in cases in
271
which immediate risk of permanent damage to the recipient's
272
health is alleged. The grievance process, when used, must be
273
completed in time to permit the recipient to disenroll no later
274
than the first day of the second month after the month the
275
disenrollment request was made. If the capitated managed care
276
network, as a result of the grievance process, approves an
277
enrollee's request to disenroll, the agency is not required to
278
make a determination in the case. The agency must make a
279
determination and take final action on a recipient's request so
280
that disenrollment occurs no later than the first day of the
281
second month after the month the request was made. If the agency
282
fails to act within the specified timeframe, the recipient's
283
request to disenroll is deemed to be approved as of the date
284
agency action was required. Recipients who disagree with the
285
agency's finding that cause does not exist for disenrollment
286
shall be advised of their right to pursue a Medicaid fair hearing
287
to dispute the agency's finding. When a specialty provider
288
service network or specialty managed care plan first becomes
289
available in a geographic area, beneficiaries meeting diagnostic
290
criteria shall be offered an open enrollment period during which
291
they may choose to reenroll in a specialty provider service
292
network or specialty managed care plan.
293
Section 3. This act shall take effect July 1, 2008.
CODING: Words stricken are deletions; words underlined are additions.