Florida Senate - 2009 SB 1448
By Senator Lynn
7-00170-09 20091448__
1 A bill to be entitled
2 An act relating to Medicaid managed care plans;
3 amending s. 409.912, F.S.; requiring that an entity
4 contracting with the Agency for Health Care
5 Administration to provide certain health care services
6 continue to offer previously authorized services while
7 prior authorization is processed, pay certain claims,
8 and develop and maintain an informal grievance system;
9 defining the term “clean claim”; requiring that the
10 agency establish a formal grievance process; providing
11 an effective date.
12
13 Be It Enacted by the Legislature of the State of Florida:
14
15 Section 1. Paragraph (b) of subsection (4) of section
16 409.912, Florida Statutes, is amended to read:
17 409.912 Cost-effective purchasing of health care.—The
18 agency shall purchase goods and services for Medicaid recipients
19 in the most cost-effective manner consistent with the delivery
20 of quality medical care. To ensure that medical services are
21 effectively utilized, the agency may, in any case, require a
22 confirmation or second physician's opinion of the correct
23 diagnosis for purposes of authorizing future services under the
24 Medicaid program. This section does not restrict access to
25 emergency services or poststabilization care services as defined
26 in 42 C.F.R. part 438.114. Such confirmation or second opinion
27 shall be rendered in a manner approved by the agency. The agency
28 shall maximize the use of prepaid per capita and prepaid
29 aggregate fixed-sum basis services when appropriate and other
30 alternative service delivery and reimbursement methodologies,
31 including competitive bidding pursuant to s. 287.057, designed
32 to facilitate the cost-effective purchase of a case-managed
33 continuum of care. The agency shall also require providers to
34 minimize the exposure of recipients to the need for acute
35 inpatient, custodial, and other institutional care and the
36 inappropriate or unnecessary use of high-cost services. The
37 agency shall contract with a vendor to monitor and evaluate the
38 clinical practice patterns of providers in order to identify
39 trends that are outside the normal practice patterns of a
40 provider's professional peers or the national guidelines of a
41 provider's professional association. The vendor must be able to
42 provide information and counseling to a provider whose practice
43 patterns are outside the norms, in consultation with the agency,
44 to improve patient care and reduce inappropriate utilization.
45 The agency may mandate prior authorization, drug therapy
46 management, or disease management participation for certain
47 populations of Medicaid beneficiaries, certain drug classes, or
48 particular drugs to prevent fraud, abuse, overuse, and possible
49 dangerous drug interactions. The Pharmaceutical and Therapeutics
50 Committee shall make recommendations to the agency on drugs for
51 which prior authorization is required. The agency shall inform
52 the Pharmaceutical and Therapeutics Committee of its decisions
53 regarding drugs subject to prior authorization. The agency is
54 authorized to limit the entities it contracts with or enrolls as
55 Medicaid providers by developing a provider network through
56 provider credentialing. The agency may competitively bid single
57 source-provider contracts if procurement of goods or services
58 results in demonstrated cost savings to the state without
59 limiting access to care. The agency may limit its network based
60 on the assessment of beneficiary access to care, provider
61 availability, provider quality standards, time and distance
62 standards for access to care, the cultural competence of the
63 provider network, demographic characteristics of Medicaid
64 beneficiaries, practice and provider-to-beneficiary standards,
65 appointment wait times, beneficiary use of services, provider
66 turnover, provider profiling, provider licensure history,
67 previous program integrity investigations and findings, peer
68 review, provider Medicaid policy and billing compliance records,
69 clinical and medical record audits, and other factors. Providers
70 shall not be entitled to enrollment in the Medicaid provider
71 network. The agency shall determine instances in which allowing
72 Medicaid beneficiaries to purchase durable medical equipment and
73 other goods is less expensive to the Medicaid program than long
74 term rental of the equipment or goods. The agency may establish
75 rules to facilitate purchases in lieu of long-term rentals in
76 order to protect against fraud and abuse in the Medicaid program
77 as defined in s. 409.913. The agency may seek federal waivers
78 necessary to administer these policies.
79 (4) The agency may contract with:
80 (b) An entity that is providing comprehensive behavioral
81 health care services to certain Medicaid recipients through a
82 capitated, prepaid arrangement pursuant to the federal waiver
83 provided for by s. 409.905(5). Such an entity must be licensed
84 under chapter 624, chapter 636, or chapter 641 and must possess
85 the clinical systems and operational competence to manage risk
86 and provide comprehensive behavioral health care to Medicaid
87 recipients. As used in this paragraph, the term “comprehensive
88 behavioral health care services” means covered mental health and
89 substance abuse treatment services that are available to
90 Medicaid recipients. The secretary of the Department of Children
91 and Family Services shall approve provisions of procurements
92 related to children in the department's care or custody prior to
93 enrolling such children in a prepaid behavioral health plan. Any
94 contract awarded under this paragraph must be competitively
95 procured. In developing the behavioral health care prepaid plan
96 procurement document, the agency shall ensure that the
97 procurement document requires the contractor to develop and
98 implement a plan to ensure compliance with s. 394.4574 related
99 to services provided to residents of licensed assisted living
100 facilities that hold a limited mental health license. Except as
101 provided in subparagraph 8., and except in counties where the
102 Medicaid managed care pilot program is authorized pursuant to s.
103 409.91211, the agency shall seek federal approval to contract
104 with a single entity meeting these requirements to provide
105 comprehensive behavioral health care services to all Medicaid
106 recipients not enrolled in a Medicaid managed care plan
107 authorized under s. 409.91211 or a Medicaid health maintenance
108 organization in an AHCA area. In an AHCA area where the Medicaid
109 managed care pilot program is authorized pursuant to s.
110 409.91211 in one or more counties, the agency may procure a
111 contract with a single entity to serve the remaining counties as
112 an AHCA area or the remaining counties may be included with an
113 adjacent AHCA area and shall be subject to this paragraph. Each
114 entity must offer sufficient choice of providers in its network
115 to ensure recipient access to care and the opportunity to select
116 a provider with whom they are satisfied. The network shall
117 include all public mental health hospitals. To ensure unimpaired
118 access to behavioral health care services by Medicaid
119 recipients, all contracts issued pursuant to this paragraph
120 shall require 80 percent of the capitation paid to the managed
121 care plan, including health maintenance organizations, to be
122 expended for the provision of behavioral health care services.
123 In the event the managed care plan expends less than 80 percent
124 of the capitation paid pursuant to this paragraph for the
125 provision of behavioral health care services, the difference
126 shall be returned to the agency. The agency shall provide the
127 managed care plan with a certification letter indicating the
128 amount of capitation paid during each calendar year for the
129 provision of behavioral health care services pursuant to this
130 section. The agency may reimburse for substance abuse treatment
131 services on a fee-for-service basis until the agency finds that
132 adequate funds are available for capitated, prepaid
133 arrangements.
134 1. By January 1, 2001, the agency shall modify the
135 contracts with the entities providing comprehensive inpatient
136 and outpatient mental health care services to Medicaid
137 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
138 Counties, to include substance abuse treatment services.
139 2. By July 1, 2003, the agency and the Department of
140 Children and Family Services shall execute a written agreement
141 that requires collaboration and joint development of all policy,
142 budgets, procurement documents, contracts, and monitoring plans
143 that have an impact on the state and Medicaid community mental
144 health and targeted case management programs.
145 3. Except as provided in subparagraph 8., by July 1, 2006,
146 the agency and the Department of Children and Family Services
147 shall contract with managed care entities in each AHCA area
148 except area 6 or arrange to provide comprehensive inpatient and
149 outpatient mental health and substance abuse services through
150 capitated prepaid arrangements to all Medicaid recipients who
151 are eligible to participate in such plans under federal law and
152 regulation. In AHCA areas where eligible individuals number less
153 than 150,000, the agency shall contract with a single managed
154 care plan to provide comprehensive behavioral health services to
155 all recipients who are not enrolled in a Medicaid health
156 maintenance organization or a Medicaid capitated managed care
157 plan authorized under s. 409.91211. The agency may contract with
158 more than one comprehensive behavioral health provider to
159 provide care to recipients who are not enrolled in a Medicaid
160 capitated managed care plan authorized under s. 409.91211 or a
161 Medicaid health maintenance organization in AHCA areas where the
162 eligible population exceeds 150,000. In an AHCA area where the
163 Medicaid managed care pilot program is authorized pursuant to s.
164 409.91211 in one or more counties, the agency may procure a
165 contract with a single entity to serve the remaining counties as
166 an AHCA area or the remaining counties may be included with an
167 adjacent AHCA area and shall be subject to this paragraph.
168 Contracts for comprehensive behavioral health providers awarded
169 pursuant to this section shall be competitively procured. Both
170 for-profit and not-for-profit corporations shall be eligible to
171 compete. Managed care plans contracting with the agency under
172 subsection (3) shall provide and receive payment for the same
173 comprehensive behavioral health benefits as provided in AHCA
174 rules, including handbooks incorporated by reference. In AHCA
175 area 11, the agency shall contract with at least two
176 comprehensive behavioral health care providers to provide
177 behavioral health care to recipients in that area who are
178 enrolled in, or assigned to, the MediPass program. One of the
179 behavioral health care contracts shall be with the existing
180 provider service network pilot project, as described in
181 paragraph (d), for the purpose of demonstrating the cost
182 effectiveness of the provision of quality mental health services
183 through a public hospital-operated managed care model. Payment
184 shall be at an agreed-upon capitated rate to ensure cost
185 savings. Of the recipients in area 11 who are assigned to
186 MediPass under the provisions of s. 409.9122(2)(k), a minimum of
187 50,000 of those MediPass-enrolled recipients shall be assigned
188 to the existing provider service network in area 11 for their
189 behavioral care.
190 4. By October 1, 2003, the agency and the department shall
191 submit a plan to the Governor, the President of the Senate, and
192 the Speaker of the House of Representatives which provides for
193 the full implementation of capitated prepaid behavioral health
194 care in all areas of the state.
195 a. Implementation shall begin in 2003 in those AHCA areas
196 of the state where the agency is able to establish sufficient
197 capitation rates.
198 b. If the agency determines that the proposed capitation
199 rate in any area is insufficient to provide appropriate
200 services, the agency may adjust the capitation rate to ensure
201 that care will be available. The agency and the department may
202 use existing general revenue to address any additional required
203 match but may not over-obligate existing funds on an annualized
204 basis.
205 c. Subject to any limitations provided for in the General
206 Appropriations Act, the agency, in compliance with appropriate
207 federal authorization, shall develop policies and procedures
208 that allow for certification of local and state funds.
209 5. Children residing in a statewide inpatient psychiatric
210 program, or in a Department of Juvenile Justice or a Department
211 of Children and Family Services residential program approved as
212 a Medicaid behavioral health overlay services provider shall not
213 be included in a behavioral health care prepaid health plan or
214 any other Medicaid managed care plan pursuant to this paragraph.
215 6. In converting to a prepaid system of delivery, the
216 agency shall in its procurement document require an entity
217 providing only comprehensive behavioral health care services to
218 prevent the displacement of indigent care patients by enrollees
219 in the Medicaid prepaid health plan providing behavioral health
220 care services from facilities receiving state funding to provide
221 indigent behavioral health care, to facilities licensed under
222 chapter 395 which do not receive state funding for indigent
223 behavioral health care, or reimburse the unsubsidized facility
224 for the cost of behavioral health care provided to the displaced
225 indigent care patient.
226 7. Traditional community mental health providers under
227 contract with the Department of Children and Family Services
228 pursuant to part IV of chapter 394, child welfare providers
229 under contract with the Department of Children and Family
230 Services in areas 1 and 6, and inpatient mental health providers
231 licensed pursuant to chapter 395 must be offered an opportunity
232 to accept or decline a contract to participate in any provider
233 network for prepaid behavioral health services.
234 8. All Medicaid-eligible children, except children in area
235 1 and children in Highlands County, Hardee County, Polk County,
236 or Manatee County of area 6, who are open for child welfare
237 services in the HomeSafeNet system, shall receive their
238 behavioral health care services through a specialty prepaid plan
239 operated by community-based lead agencies either through a
240 single agency or formal agreements among several agencies. The
241 specialty prepaid plan must result in savings to the state
242 comparable to savings achieved in other Medicaid managed care
243 and prepaid programs. Such plan must provide mechanisms to
244 maximize state and local revenues. The specialty prepaid plan
245 shall be developed by the agency and the Department of Children
246 and Family Services. The agency is authorized to seek any
247 federal waivers to implement this initiative. Medicaid-eligible
248 children whose cases are open for child welfare services in the
249 HomeSafeNet system and who reside in AHCA area 10 are exempt
250 from the specialty prepaid plan upon the development of a
251 service delivery mechanism for children who reside in area 10 as
252 specified in s. 409.91211(3)(dd).
253 9. An entity providing comprehensive behavioral health care
254 services and licensed under chapter 624, chapter 636, or chapter
255 641 shall:
256 a. Continue services authorized by the previous entity as
257 medically necessary while prior authorization is being processed
258 under a new plan;
259 b. Pay, within 10 business days after receipt, electronic
260 clean claims containing sufficient information for processing.
261 For purposes of this paragraph, the term “clean claim” means a
262 claim that does not have any defect or impropriety, including
263 the lack of any required substantiating documentation or
264 particular circumstance requiring special treatment that
265 prevents timely payment from being made; and
266 c. Develop and maintain an informal grievance system that
267 addresses payment and contract problems with physicians licensed
268 under chapter 458 or chapter 459, psychologists licensed under
269 chapter 491, psychotherapists as defined in chapter 491, or a
270 facility operating under chapter 393, chapter 394, or chapter
271 397. The agency shall also establish a formal grievance system
272 to address those issues that are not resolved through the
273 informal grievance system.
274 Section 2. This act shall take effect July 1, 2009.