1 | A bill to be entitled |
2 | An act relating to Medicaid; amending s. 409.912, F.S.; |
3 | requiring a contract between the Agency for Health Care |
4 | Administration and certain health maintenance |
5 | organizations or entities that do not provide prepaid |
6 | health care services to set rates on a beneficiary- |
7 | specific, risk-adjusted basis; requiring that funds repaid |
8 | to the agency by managed care plans that spend less than a |
9 | certain percentage of the capitation paid to the plan to |
10 | be deposited into a trust fund by the agency and |
11 | transferred to the Department of Children and Family |
12 | Services; requiring the agency to assess interest and |
13 | fines; requiring the agency to continue to offer |
14 | beneficiaries a choice of and contract with prepaid mental |
15 | health plans under certain conditions; prohibiting |
16 | MediPass beneficiaries from enrolling in a health |
17 | maintenance organization for behavioral health services; |
18 | amending s. 409.91211, F.S.; conforming a provision to |
19 | changes made by the act; amending s. 409.9122, F.S.; |
20 | providing that mental illness is a showing of good cause |
21 | to allow a Medicaid recipient to disenroll and select |
22 | another managed care plan or MediPass after a specified |
23 | period of time; providing an effective date. |
24 |
|
25 | Be It Enacted by the Legislature of the State of Florida: |
26 |
|
27 | Section 1. Subsection (3) and paragraphs (a) and (b) of |
28 | subsection (4) of section 409.912, Florida Statutes, are amended |
29 | to read: |
30 | 409.912 Cost-effective purchasing of health care.--The |
31 | agency shall purchase goods and services for Medicaid recipients |
32 | in the most cost-effective manner consistent with the delivery |
33 | of quality medical care. To ensure that medical services are |
34 | effectively utilized, the agency may, in any case, require a |
35 | confirmation or second physician's opinion of the correct |
36 | diagnosis for purposes of authorizing future services under the |
37 | Medicaid program. This section does not restrict access to |
38 | emergency services or poststabilization care services as defined |
39 | in 42 C.F.R. part 438.114. Such confirmation or second opinion |
40 | shall be rendered in a manner approved by the agency. The agency |
41 | shall maximize the use of prepaid per capita and prepaid |
42 | aggregate fixed-sum basis services when appropriate and other |
43 | alternative service delivery and reimbursement methodologies, |
44 | including competitive bidding pursuant to s. 287.057, designed |
45 | to facilitate the cost-effective purchase of a case-managed |
46 | continuum of care. The agency shall also require providers to |
47 | minimize the exposure of recipients to the need for acute |
48 | inpatient, custodial, and other institutional care and the |
49 | inappropriate or unnecessary use of high-cost services. The |
50 | agency shall contract with a vendor to monitor and evaluate the |
51 | clinical practice patterns of providers in order to identify |
52 | trends that are outside the normal practice patterns of a |
53 | provider's professional peers or the national guidelines of a |
54 | provider's professional association. The vendor must be able to |
55 | provide information and counseling to a provider whose practice |
56 | patterns are outside the norms, in consultation with the agency, |
57 | to improve patient care and reduce inappropriate utilization. |
58 | The agency may mandate prior authorization, drug therapy |
59 | management, or disease management participation for certain |
60 | populations of Medicaid beneficiaries, certain drug classes, or |
61 | particular drugs to prevent fraud, abuse, overuse, and possible |
62 | dangerous drug interactions. The Pharmaceutical and Therapeutics |
63 | Committee shall make recommendations to the agency on drugs for |
64 | which prior authorization is required. The agency shall inform |
65 | the Pharmaceutical and Therapeutics Committee of its decisions |
66 | regarding drugs subject to prior authorization. The agency is |
67 | authorized to limit the entities it contracts with or enrolls as |
68 | Medicaid providers by developing a provider network through |
69 | provider credentialing. The agency may competitively bid single- |
70 | source-provider contracts if procurement of goods or services |
71 | results in demonstrated cost savings to the state without |
72 | limiting access to care. The agency may limit its network based |
73 | on the assessment of beneficiary access to care, provider |
74 | availability, provider quality standards, time and distance |
75 | standards for access to care, the cultural competence of the |
76 | provider network, demographic characteristics of Medicaid |
77 | beneficiaries, practice and provider-to-beneficiary standards, |
78 | appointment wait times, beneficiary use of services, provider |
79 | turnover, provider profiling, provider licensure history, |
80 | previous program integrity investigations and findings, peer |
81 | review, provider Medicaid policy and billing compliance records, |
82 | clinical and medical record audits, and other factors. Providers |
83 | shall not be entitled to enrollment in the Medicaid provider |
84 | network. The agency shall determine instances in which allowing |
85 | Medicaid beneficiaries to purchase durable medical equipment and |
86 | other goods is less expensive to the Medicaid program than long- |
87 | term rental of the equipment or goods. The agency may establish |
88 | rules to facilitate purchases in lieu of long-term rentals in |
89 | order to protect against fraud and abuse in the Medicaid program |
90 | as defined in s. 409.913. The agency may seek federal waivers |
91 | necessary to administer these policies. |
92 | (3) The agency may contract with health maintenance |
93 | organizations certified pursuant to part I of chapter 641 for |
94 | the provision of services to recipients. Any such contract must |
95 | set rates on a beneficiary-specific, risk-adjusted basis, based |
96 | on the beneficiary's age, geographic area, eligibility category, |
97 | gender, prior use of services, diagnoses, and prescription use, |
98 | consistent with the methodology established for the reform areas |
99 | referenced in s. 409.91211. |
100 | (4) The agency may contract with: |
101 | (a) An entity that provides no prepaid health care |
102 | services other than Medicaid services under contract with the |
103 | agency and which is owned and operated by a county, county |
104 | health department, or county-owned and operated hospital to |
105 | provide health care services on a prepaid or fixed-sum basis to |
106 | recipients, which entity may provide such prepaid services |
107 | either directly or through arrangements with other providers. |
108 | Such prepaid health care services entities must be licensed |
109 | under parts I and III of chapter 641. An entity recognized under |
110 | this paragraph which demonstrates to the satisfaction of the |
111 | Office of Insurance Regulation of the Financial Services |
112 | Commission that it is backed by the full faith and credit of the |
113 | county in which it is located may be exempted from s. 641.225. |
114 | Any contract with an entity described in this paragraph must set |
115 | rates on a beneficiary-specific, risk-adjusted basis based on |
116 | the beneficiary's age, geographic area, eligibility category, |
117 | gender, prior use of services, diagnoses, and prescription use, |
118 | consistent with the methodology established for the reform areas |
119 | referenced in s. 409.91211. |
120 | (b) An entity that is providing comprehensive behavioral |
121 | health care services to certain Medicaid recipients through a |
122 | capitated, prepaid arrangement pursuant to the federal waiver |
123 | provided for by s. 409.905(5). Such an entity must be licensed |
124 | under chapter 624, chapter 636, or chapter 641 and must possess |
125 | the clinical systems and operational competence to manage risk |
126 | and provide comprehensive behavioral health care to Medicaid |
127 | recipients. As used in this paragraph, the term "comprehensive |
128 | behavioral health care services" means covered mental health and |
129 | substance abuse treatment services that are available to |
130 | Medicaid recipients. The secretary of the Department of Children |
131 | and Family Services shall approve provisions of procurements |
132 | related to children in the department's care or custody prior to |
133 | enrolling such children in a prepaid behavioral health plan. Any |
134 | contract awarded under this paragraph must be competitively |
135 | procured. In developing the behavioral health care prepaid plan |
136 | procurement document, the agency shall ensure that the |
137 | procurement document requires the contractor to develop and |
138 | implement a plan to ensure compliance with s. 394.4574 related |
139 | to services provided to residents of licensed assisted living |
140 | facilities that hold a limited mental health license. Except as |
141 | provided in subparagraph 8., and except in counties where the |
142 | Medicaid managed care pilot program is authorized pursuant to s. |
143 | 409.91211, the agency shall seek federal approval to contract |
144 | with a single entity meeting these requirements to provide |
145 | comprehensive behavioral health care services to all Medicaid |
146 | recipients not enrolled in a Medicaid managed care plan |
147 | authorized under s. 409.91211 or a Medicaid health maintenance |
148 | organization in an AHCA area. In an AHCA area where the Medicaid |
149 | managed care pilot program is authorized pursuant to s. |
150 | 409.91211 in one or more counties, the agency may procure a |
151 | contract with a single entity to serve the remaining counties as |
152 | an AHCA area or the remaining counties may be included with an |
153 | adjacent AHCA area and shall be subject to this paragraph. Each |
154 | entity must offer sufficient choice of providers in its network |
155 | to ensure recipient access to care and the opportunity to select |
156 | a provider with whom they are satisfied. The network shall |
157 | include all public mental health hospitals. To ensure unimpaired |
158 | access to behavioral health care services by Medicaid |
159 | recipients, all contracts issued pursuant to this paragraph |
160 | shall require 80 percent of the capitation paid to the managed |
161 | care plan, including health maintenance organizations, to be |
162 | expended for the provision of behavioral health care services. |
163 | In the event the managed care plan expends less than 80 percent |
164 | of the capitation paid pursuant to this paragraph for the |
165 | provision of behavioral health care services, the difference |
166 | shall be returned to the agency. The agency shall provide the |
167 | managed care plan with a certification letter indicating the |
168 | amount of capitation paid during each calendar year for the |
169 | provision of behavioral health care services pursuant to this |
170 | section. Any funds repaid to the agency by a managed care plan |
171 | that fails to meet the 80-percent requirement shall be deposited |
172 | into a trust fund by the agency and transferred to the |
173 | Department of Children and Family Services for reinvestment in |
174 | community health services provided by providers enrolled in the |
175 | networks of managed care plans that failed to the meet the 80- |
176 | percent requirement. The agency shall assess interest and fines |
177 | on the amounts below the 80-percent threshold. The agency may |
178 | reimburse for substance abuse treatment services on a fee-for- |
179 | service basis until the agency finds that adequate funds are |
180 | available for capitated, prepaid arrangements. The agency shall |
181 | continue to offer beneficiaries a choice of and contract with |
182 | prepaid mental health plans as long as the agency operates its |
183 | MediPass program. However, beneficiaries enrolled in MediPass |
184 | may not be enrolled in a health maintenance organization for |
185 | behavioral health services. |
186 | 1. By January 1, 2001, the agency shall modify the |
187 | contracts with the entities providing comprehensive inpatient |
188 | and outpatient mental health care services to Medicaid |
189 | recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk |
190 | Counties, to include substance abuse treatment services. |
191 | 2. By July 1, 2003, the agency and the Department of |
192 | Children and Family Services shall execute a written agreement |
193 | that requires collaboration and joint development of all policy, |
194 | budgets, procurement documents, contracts, and monitoring plans |
195 | that have an impact on the state and Medicaid community mental |
196 | health and targeted case management programs. |
197 | 3. Except as provided in subparagraph 8., by July 1, 2006, |
198 | the agency and the Department of Children and Family Services |
199 | shall contract with managed care entities in each AHCA area |
200 | except area 6 or arrange to provide comprehensive inpatient and |
201 | outpatient mental health and substance abuse services through |
202 | capitated prepaid arrangements to all Medicaid recipients who |
203 | are eligible to participate in such plans under federal law and |
204 | regulation. In AHCA areas where eligible individuals number less |
205 | than 150,000, the agency shall contract with a single managed |
206 | care plan to provide comprehensive behavioral health services to |
207 | all recipients who are not enrolled in a Medicaid health |
208 | maintenance organization or a Medicaid capitated managed care |
209 | plan authorized under s. 409.91211. The agency may contract with |
210 | more than one comprehensive behavioral health provider to |
211 | provide care to recipients who are not enrolled in a Medicaid |
212 | capitated managed care plan authorized under s. 409.91211 or a |
213 | Medicaid health maintenance organization in AHCA areas where the |
214 | eligible population exceeds 150,000. In an AHCA area where the |
215 | Medicaid managed care pilot program is authorized pursuant to s. |
216 | 409.91211 in one or more counties, the agency may procure a |
217 | contract with a single entity to serve the remaining counties as |
218 | an AHCA area or the remaining counties may be included with an |
219 | adjacent AHCA area and shall be subject to this paragraph. |
220 | Contracts for comprehensive behavioral health providers awarded |
221 | pursuant to this section shall be competitively procured. Both |
222 | for-profit and not-for-profit corporations shall be eligible to |
223 | compete. Managed care plans contracting with the agency under |
224 | subsection (3) shall provide and receive payment for the same |
225 | comprehensive behavioral health benefits as provided in AHCA |
226 | rules, including handbooks incorporated by reference. In AHCA |
227 | area 11, the agency shall contract with at least two |
228 | comprehensive behavioral health care providers to provide |
229 | behavioral health care to recipients in that area who are |
230 | enrolled in, or assigned to, the MediPass program. One of the |
231 | behavioral health care contracts shall be with the existing |
232 | provider service network pilot project, as described in |
233 | paragraph (d), for the purpose of demonstrating the cost- |
234 | effectiveness of the provision of quality mental health services |
235 | through a public hospital-operated managed care model. Payment |
236 | shall be at an agreed-upon capitated rate to ensure cost |
237 | savings. Of the recipients in area 11 who are assigned to |
238 | MediPass under the provisions of s. 409.9122(2)(k), a minimum of |
239 | 50,000 of those MediPass-enrolled recipients shall be assigned |
240 | to the existing provider service network in area 11 for their |
241 | behavioral care. |
242 | 4. By October 1, 2003, the agency and the department shall |
243 | submit a plan to the Governor, the President of the Senate, and |
244 | the Speaker of the House of Representatives which provides for |
245 | the full implementation of capitated prepaid behavioral health |
246 | care in all areas of the state. |
247 | a. Implementation shall begin in 2003 in those AHCA areas |
248 | of the state where the agency is able to establish sufficient |
249 | capitation rates. |
250 | b. If the agency determines that the proposed capitation |
251 | rate in any area is insufficient to provide appropriate |
252 | services, the agency may adjust the capitation rate to ensure |
253 | that care will be available. The agency and the department may |
254 | use existing general revenue to address any additional required |
255 | match but may not over-obligate existing funds on an annualized |
256 | basis. |
257 | c. Subject to any limitations provided for in the General |
258 | Appropriations Act, the agency, in compliance with appropriate |
259 | federal authorization, shall develop policies and procedures |
260 | that allow for certification of local and state funds. |
261 | 5. Children residing in a statewide inpatient psychiatric |
262 | program, or in a Department of Juvenile Justice or a Department |
263 | of Children and Family Services residential program approved as |
264 | a Medicaid behavioral health overlay services provider shall not |
265 | be included in a behavioral health care prepaid health plan or |
266 | any other Medicaid managed care plan pursuant to this paragraph. |
267 | 6. In converting to a prepaid system of delivery, the |
268 | agency shall in its procurement document require an entity |
269 | providing only comprehensive behavioral health care services to |
270 | prevent the displacement of indigent care patients by enrollees |
271 | in the Medicaid prepaid health plan providing behavioral health |
272 | care services from facilities receiving state funding to provide |
273 | indigent behavioral health care, to facilities licensed under |
274 | chapter 395 which do not receive state funding for indigent |
275 | behavioral health care, or reimburse the unsubsidized facility |
276 | for the cost of behavioral health care provided to the displaced |
277 | indigent care patient. |
278 | 7. Traditional community mental health providers under |
279 | contract with the Department of Children and Family Services |
280 | pursuant to part IV of chapter 394, child welfare providers |
281 | under contract with the Department of Children and Family |
282 | Services in areas 1 and 6, and inpatient mental health providers |
283 | licensed pursuant to chapter 395 must be offered an opportunity |
284 | to accept or decline a contract to participate in any provider |
285 | network for prepaid behavioral health services. |
286 | 8. All Medicaid-eligible children, except children in area |
287 | 1 and children in Highlands County, Hardee County, Polk County, |
288 | or Manatee County of area 6, who are open for child welfare |
289 | services in the HomeSafeNet system, shall receive their |
290 | behavioral health care services through a specialty prepaid plan |
291 | operated by community-based lead agencies either through a |
292 | single agency or formal agreements among several agencies. The |
293 | specialty prepaid plan must result in savings to the state |
294 | comparable to savings achieved in other Medicaid managed care |
295 | and prepaid programs. Such plan must provide mechanisms to |
296 | maximize state and local revenues. The specialty prepaid plan |
297 | shall be developed by the agency and the Department of Children |
298 | and Family Services. The agency is authorized to seek any |
299 | federal waivers to implement this initiative. Medicaid-eligible |
300 | children whose cases are open for child welfare services in the |
301 | HomeSafeNet system and who reside in AHCA area 10 are exempt |
302 | from the specialty prepaid plan upon the development of a |
303 | service delivery mechanism for children who reside in area 10 as |
304 | specified in s. 409.91211(3)(dd). |
305 | Section 2. Paragraph (w) of subsection (3) of section |
306 | 409.91211, Florida Statutes, is amended to read: |
307 | 409.91211 Medicaid managed care pilot program.-- |
308 | (3) The agency shall have the following powers, duties, |
309 | and responsibilities with respect to the pilot program: |
310 | (w) To implement procedures to minimize the risk of |
311 | Medicaid fraud and abuse in all plans operating in the Medicaid |
312 | managed care pilot program authorized in this section. |
313 | 1. The agency shall ensure that applicable provisions of |
314 | this chapter and chapters 414, 626, 641, and 932 which relate to |
315 | Medicaid fraud and abuse are applied and enforced at the |
316 | demonstration project sites. |
317 | 2. Providers must have the certification, license, and |
318 | credentials that are required by law and waiver requirements. |
319 | 3. The agency shall ensure that the plan is in compliance |
320 | with s. 409.912(4)(b), (21), s. 409.912(21) and (22). |
321 | 4. The agency shall require that each plan establish |
322 | functions and activities governing program integrity in order to |
323 | reduce the incidence of fraud and abuse. Plans must report |
324 | instances of fraud and abuse pursuant to chapter 641. |
325 | 5. The plan shall have written administrative and |
326 | management arrangements or procedures, including a mandatory |
327 | compliance plan, which are designed to guard against fraud and |
328 | abuse. The plan shall designate a compliance officer who has |
329 | sufficient experience in health care. |
330 | 6.a. The agency shall require all managed care plan |
331 | contractors in the pilot program to report all instances of |
332 | suspected fraud and abuse. A failure to report instances of |
333 | suspected fraud and abuse is a violation of law and subject to |
334 | the penalties provided by law. |
335 | b. An instance of fraud and abuse in the managed care |
336 | plan, including, but not limited to, defrauding the state health |
337 | care benefit program by misrepresentation of fact in reports, |
338 | claims, certifications, enrollment claims, demographic |
339 | statistics, or patient-encounter data; misrepresentation of the |
340 | qualifications of persons rendering health care and ancillary |
341 | services; bribery and false statements relating to the delivery |
342 | of health care; unfair and deceptive marketing practices; and |
343 | false claims actions in the provision of managed care, is a |
344 | violation of law and subject to the penalties provided by law. |
345 | c. The agency shall require that all contractors make all |
346 | files and relevant billing and claims data accessible to state |
347 | regulators and investigators and that all such data is linked |
348 | into a unified system to ensure consistent reviews and |
349 | investigations. |
350 | Section 3. Paragraph (i) of subsection (2) of section |
351 | 409.9122, Florida Statutes, is amended to read: |
352 | 409.9122 Mandatory Medicaid managed care enrollment; |
353 | programs and procedures.-- |
354 | (2) |
355 | (i) After a recipient has made his or her selection or has |
356 | been enrolled in a managed care plan or MediPass, the recipient |
357 | shall have 90 days to exercise the opportunity to voluntarily |
358 | disenroll and select another managed care plan or MediPass. |
359 | After 90 days, no further changes may be made except for good |
360 | cause. Good cause includes, but is not limited to, poor quality |
361 | of care, lack of access to necessary specialty services, an |
362 | unreasonable delay or denial of service, mental illness of the |
363 | recipient, or fraudulent enrollment. The agency shall develop |
364 | criteria for good cause disenrollment for chronically ill and |
365 | disabled populations who are assigned to managed care plans if |
366 | more appropriate care is available through the MediPass program. |
367 | The agency must make a determination as to whether cause exists. |
368 | However, the agency may require a recipient to use the managed |
369 | care plan's or MediPass grievance process prior to the agency's |
370 | determination of cause, except in cases in which immediate risk |
371 | of permanent damage to the recipient's health is alleged. The |
372 | grievance process, when utilized, must be completed in time to |
373 | permit the recipient to disenroll by the first day of the second |
374 | month after the month the disenrollment request was made. If the |
375 | managed care plan or MediPass, as a result of the grievance |
376 | process, approves an enrollee's request to disenroll, the agency |
377 | is not required to make a determination in the case. The agency |
378 | must make a determination and take final action on a recipient's |
379 | request so that disenrollment occurs no later than the first day |
380 | of the second month after the month the request was made. If the |
381 | agency fails to act within the specified timeframe, the |
382 | recipient's request to disenroll is deemed to be approved as of |
383 | the date agency action was required. Recipients who disagree |
384 | with the agency's finding that cause does not exist for |
385 | disenrollment shall be advised of their right to pursue a |
386 | Medicaid fair hearing to dispute the agency's finding. |
387 | Section 4. This act shall take effect upon becoming a law. |