HB 859

1	A bill to be entitled
2	An act relating to Medicaid managed care plans; amending
3	s. 409.912, F.S.; requiring managed care plans to continue
4	to offer previously authorized services while prior
5	authorization is processed, pay certain claims, and
6	provide a grievance system; providing a definition;
7	providing an effective date.
8
9	Be It Enacted by the Legislature of the State of Florida:
10
11	Section 1.  Paragraph (b) of subsection (4) of section
12	409.912, Florida Statutes, is amended to read:
13	409.912  Cost-effective purchasing of health care.--The
14	agency shall purchase goods and services for Medicaid recipients
15	in the most cost-effective manner consistent with the delivery
16	of quality medical care. To ensure that medical services are
17	effectively utilized, the agency may, in any case, require a
18	confirmation or second physician's opinion of the correct
19	diagnosis for purposes of authorizing future services under the
20	Medicaid program. This section does not restrict access to
21	emergency services or poststabilization care services as defined
22	in 42 C.F.R. part 438.114. Such confirmation or second opinion
23	shall be rendered in a manner approved by the agency. The agency
24	shall maximize the use of prepaid per capita and prepaid
25	aggregate fixed-sum basis services when appropriate and other
26	alternative service delivery and reimbursement methodologies,
27	including competitive bidding pursuant to s. 287.057, designed
28	to facilitate the cost-effective purchase of a case-managed
29	continuum of care. The agency shall also require providers to
30	minimize the exposure of recipients to the need for acute
31	inpatient, custodial, and other institutional care and the
32	inappropriate or unnecessary use of high-cost services. The
33	agency shall contract with a vendor to monitor and evaluate the
34	clinical practice patterns of providers in order to identify
35	trends that are outside the normal practice patterns of a
36	provider's professional peers or the national guidelines of a
37	provider's professional association. The vendor must be able to
38	provide information and counseling to a provider whose practice
39	patterns are outside the norms, in consultation with the agency,
40	to improve patient care and reduce inappropriate utilization.
41	The agency may mandate prior authorization, drug therapy
42	management, or disease management participation for certain
43	populations of Medicaid beneficiaries, certain drug classes, or
44	particular drugs to prevent fraud, abuse, overuse, and possible
45	dangerous drug interactions. The Pharmaceutical and Therapeutics
46	Committee shall make recommendations to the agency on drugs for
47	which prior authorization is required. The agency shall inform
48	the Pharmaceutical and Therapeutics Committee of its decisions
49	regarding drugs subject to prior authorization. The agency is
50	authorized to limit the entities it contracts with or enrolls as
51	Medicaid providers by developing a provider network through
52	provider credentialing. The agency may competitively bid single-
53	source-provider contracts if procurement of goods or services
54	results in demonstrated cost savings to the state without
55	limiting access to care. The agency may limit its network based
56	on the assessment of beneficiary access to care, provider
57	availability, provider quality standards, time and distance
58	standards for access to care, the cultural competence of the
59	provider network, demographic characteristics of Medicaid
60	beneficiaries, practice and provider-to-beneficiary standards,
61	appointment wait times, beneficiary use of services, provider
62	turnover, provider profiling, provider licensure history,
63	previous program integrity investigations and findings, peer
64	review, provider Medicaid policy and billing compliance records,
65	clinical and medical record audits, and other factors. Providers
66	shall not be entitled to enrollment in the Medicaid provider
67	network. The agency shall determine instances in which allowing
68	Medicaid beneficiaries to purchase durable medical equipment and
69	other goods is less expensive to the Medicaid program than long-
70	term rental of the equipment or goods. The agency may establish
71	rules to facilitate purchases in lieu of long-term rentals in
72	order to protect against fraud and abuse in the Medicaid program
73	as defined in s. 409.913. The agency may seek federal waivers
74	necessary to administer these policies.
75	(4)  The agency may contract with:
76	(b)  An entity that is providing comprehensive behavioral
77	health care services to certain Medicaid recipients through a
78	capitated, prepaid arrangement pursuant to the federal waiver
79	provided for by s. 409.905(5). Such an entity must be licensed
80	under chapter 624, chapter 636, or chapter 641 and must possess
81	the clinical systems and operational competence to manage risk
82	and provide comprehensive behavioral health care to Medicaid
83	recipients. As used in this paragraph, the term "comprehensive
84	behavioral health care services" means covered mental health and
85	substance abuse treatment services that are available to
86	Medicaid recipients. The secretary of the Department of Children
87	and Family Services shall approve provisions of procurements
88	related to children in the department's care or custody prior to
89	enrolling such children in a prepaid behavioral health plan. Any
90	contract awarded under this paragraph must be competitively
91	procured. In developing the behavioral health care prepaid plan
92	procurement document, the agency shall ensure that the
93	procurement document requires the contractor to develop and
94	implement a plan to ensure compliance with s. 394.4574 related
95	to services provided to residents of licensed assisted living
96	facilities that hold a limited mental health license. Except as
97	provided in subparagraph 8., and except in counties where the
98	Medicaid managed care pilot program is authorized pursuant to s.
99	409.91211, the agency shall seek federal approval to contract
100	with a single entity meeting these requirements to provide
101	comprehensive behavioral health care services to all Medicaid
102	recipients not enrolled in a Medicaid managed care plan
103	authorized under s. 409.91211 or a Medicaid health maintenance
104	organization in an AHCA area. In an AHCA area where the Medicaid
105	managed care pilot program is authorized pursuant to s.
106	409.91211 in one or more counties, the agency may procure a
107	contract with a single entity to serve the remaining counties as
108	an AHCA area or the remaining counties may be included with an
109	adjacent AHCA area and shall be subject to this paragraph. Each
110	entity must offer sufficient choice of providers in its network
111	to ensure recipient access to care and the opportunity to select
112	a provider with whom they are satisfied. The network shall
113	include all public mental health hospitals. To ensure unimpaired
114	access to behavioral health care services by Medicaid
115	recipients, all contracts issued pursuant to this paragraph
116	shall require 80 percent of the capitation paid to the managed
117	care plan, including health maintenance organizations, to be
118	expended for the provision of behavioral health care services.
119	In the event the managed care plan expends less than 80 percent
120	of the capitation paid pursuant to this paragraph for the
121	provision of behavioral health care services, the difference
122	shall be returned to the agency. The agency shall provide the
123	managed care plan with a certification letter indicating the
124	amount of capitation paid during each calendar year for the
125	provision of behavioral health care services pursuant to this
126	section. The agency may reimburse for substance abuse treatment
127	services on a fee-for-service basis until the agency finds that
128	adequate funds are available for capitated, prepaid
129	arrangements.
130	1.  By January 1, 2001, the agency shall modify the
131	contracts with the entities providing comprehensive inpatient
132	and outpatient mental health care services to Medicaid
133	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
134	Counties, to include substance abuse treatment services.
135	2.  By July 1, 2003, the agency and the Department of
136	Children and Family Services shall execute a written agreement
137	that requires collaboration and joint development of all policy,
138	budgets, procurement documents, contracts, and monitoring plans
139	that have an impact on the state and Medicaid community mental
140	health and targeted case management programs.
141	3.  Except as provided in subparagraph 8., by July 1, 2006,
142	the agency and the Department of Children and Family Services
143	shall contract with managed care entities in each AHCA area
144	except area 6 or arrange to provide comprehensive inpatient and
145	outpatient mental health and substance abuse services through
146	capitated prepaid arrangements to all Medicaid recipients who
147	are eligible to participate in such plans under federal law and
148	regulation. In AHCA areas where eligible individuals number less
149	than 150,000, the agency shall contract with a single managed
150	care plan to provide comprehensive behavioral health services to
151	all recipients who are not enrolled in a Medicaid health
152	maintenance organization or a Medicaid capitated managed care
153	plan authorized under s. 409.91211. The agency may contract with
154	more than one comprehensive behavioral health provider to
155	provide care to recipients who are not enrolled in a Medicaid
156	capitated managed care plan authorized under s. 409.91211 or a
157	Medicaid health maintenance organization in AHCA areas where the
158	eligible population exceeds 150,000. In an AHCA area where the
159	Medicaid managed care pilot program is authorized pursuant to s.
160	409.91211 in one or more counties, the agency may procure a
161	contract with a single entity to serve the remaining counties as
162	an AHCA area or the remaining counties may be included with an
163	adjacent AHCA area and shall be subject to this paragraph.
164	Contracts for comprehensive behavioral health providers awarded
165	pursuant to this section shall be competitively procured. Both
166	for-profit and not-for-profit corporations shall be eligible to
167	compete. Managed care plans contracting with the agency under
168	subsection (3) shall provide and receive payment for the same
169	comprehensive behavioral health benefits as provided in AHCA
170	rules, including handbooks incorporated by reference. In AHCA
171	area 11, the agency shall contract with at least two
172	comprehensive behavioral health care providers to provide
173	behavioral health care to recipients in that area who are
174	enrolled in, or assigned to, the MediPass program. One of the
175	behavioral health care contracts shall be with the existing
176	provider service network pilot project, as described in
177	paragraph (d), for the purpose of demonstrating the cost-
178	effectiveness of the provision of quality mental health services
179	through a public hospital-operated managed care model. Payment
180	shall be at an agreed-upon capitated rate to ensure cost
181	savings. Of the recipients in area 11 who are assigned to
182	MediPass under the provisions of s. 409.9122(2)(k), a minimum of
183	50,000 of those MediPass-enrolled recipients shall be assigned
184	to the existing provider service network in area 11 for their
185	behavioral care.
186	4.  By October 1, 2003, the agency and the department shall
187	submit a plan to the Governor, the President of the Senate, and
188	the Speaker of the House of Representatives which provides for
189	the full implementation of capitated prepaid behavioral health
190	care in all areas of the state.
191	a.  Implementation shall begin in 2003 in those AHCA areas
192	of the state where the agency is able to establish sufficient
193	capitation rates.
194	b.  If the agency determines that the proposed capitation
195	rate in any area is insufficient to provide appropriate
196	services, the agency may adjust the capitation rate to ensure
197	that care will be available. The agency and the department may
198	use existing general revenue to address any additional required
199	match but may not over-obligate existing funds on an annualized
200	basis.
201	c.  Subject to any limitations provided for in the General
202	Appropriations Act, the agency, in compliance with appropriate
203	federal authorization, shall develop policies and procedures
204	that allow for certification of local and state funds.
205	5.  Children residing in a statewide inpatient psychiatric
206	program, or in a Department of Juvenile Justice or a Department
207	of Children and Family Services residential program approved as
208	a Medicaid behavioral health overlay services provider shall not
209	be included in a behavioral health care prepaid health plan or
210	any other Medicaid managed care plan pursuant to this paragraph.
211	6.  In converting to a prepaid system of delivery, the
212	agency shall in its procurement document require an entity
213	providing only comprehensive behavioral health care services to
214	prevent the displacement of indigent care patients by enrollees
215	in the Medicaid prepaid health plan providing behavioral health
216	care services from facilities receiving state funding to provide
217	indigent behavioral health care, to facilities licensed under
218	chapter 395 which do not receive state funding for indigent
219	behavioral health care, or reimburse the unsubsidized facility
220	for the cost of behavioral health care provided to the displaced
221	indigent care patient.
222	7.  Traditional community mental health providers under
223	contract with the Department of Children and Family Services
224	pursuant to part IV of chapter 394, child welfare providers
225	under contract with the Department of Children and Family
226	Services in areas 1 and 6, and inpatient mental health providers
227	licensed pursuant to chapter 395 must be offered an opportunity
228	to accept or decline a contract to participate in any provider
229	network for prepaid behavioral health services.
230	8.  For fiscal year 2004-2005, all Medicaid eligible
231	children, except children in areas 1 and 6, whose cases are open
232	for child welfare services in the HomeSafeNet system, shall be
233	enrolled in MediPass or in Medicaid fee-for-service and all
234	their behavioral health care services including inpatient,
235	outpatient psychiatric, community mental health, and case
236	management shall be reimbursed on a fee-for-service basis.
237	Beginning July 1, 2005, such children, who are open for child
238	welfare services in the HomeSafeNet system, shall receive their
239	behavioral health care services through a specialty prepaid plan
240	operated by community-based lead agencies either through a
241	single agency or formal agreements among several agencies. The
242	specialty prepaid plan must result in savings to the state
243	comparable to savings achieved in other Medicaid managed care
244	and prepaid programs. Such plan must provide mechanisms to
245	maximize state and local revenues. The specialty prepaid plan
246	shall be developed by the agency and the Department of Children
247	and Family Services. The agency is authorized to seek any
248	federal waivers to implement this initiative. Medicaid-eligible
249	children whose cases are open for child welfare services in the
250	HomeSafeNet system and who reside in AHCA area 10 are exempt
251	from the specialty prepaid plan upon the development of a
252	service delivery mechanism for children who reside in area 10 as
253	specified in s. 409.91211(3)(dd).
254	9.  An entity that provides comprehensive behavioral health
255	care services and is licensed under chapter 624, chapter 636, or
256	chapter 641 shall:
257	a.  Continue services authorized by the previous entity as
258	medically necessary while prior authorization is being processed
259	under a new plan;
260	b.  Pay, within 10 business days after receipt, electronic
261	clean claims containing sufficient information for processing.
262	For purposes of this sub-subparagraph, the term "clean claim"
263	means a claim that has no defect or impropriety, including the
264	lack of any required substantiating documentation or particular
265	circumstance requiring special treatment that prevents timely
266	payment being made; and
267	c.  Develop and maintain an informal grievance system that
268	addresses payment and contract problems with a physician
269	licensed under chapter 458 or chapter 459, a psychologist
270	licensed under chapter 490, a psychotherapist licensed under
271	chapter 491, or a facility licensed under chapter 393, chapter
272	394, or chapter 397. The agency shall also establish a formal
273	grievance system to address those issues that are not resolved
274	through the informal grievance system.
275	Section 2.  This act shall take effect July 1, 2008.

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