HB 1529

1
A bill to be entitled
2An act relating to Medicaid; amending s. 409.912, F.S.;
3requiring a contract between the Agency for Health Care
4Administration and certain health maintenance
5organizations or entities that do not provide prepaid
6health care services to set rates on a beneficiary-
7specific, risk-adjusted basis; requiring that funds repaid
8to the agency by managed care plans that spend less than a
9certain percentage of the capitation paid to the plan to
10be deposited into a trust fund by the agency and
11transferred to the Department of Children and Family
12Services; requiring the agency to assess interest and
13fines; requiring the agency to continue to offer
14beneficiaries a choice of and contract with prepaid mental
15health plans under certain conditions; prohibiting
16MediPass beneficiaries from enrolling in a health
17maintenance organization for behavioral health services;
18amending s. 409.91211, F.S.; conforming a provision to
19changes made by the act; amending s. 409.9122, F.S.;
20providing that mental illness is a showing of good cause
21to allow a Medicaid recipient to disenroll and select
22another managed care plan or MediPass after a specified
23period of time; providing an effective date.
24
25Be It Enacted by the Legislature of the State of Florida:
26
27     Section 1.  Subsection (3) and paragraphs (a) and (b) of
28subsection (4) of section 409.912, Florida Statutes, are amended
29to read:
30     409.912  Cost-effective purchasing of health care.--The
31agency shall purchase goods and services for Medicaid recipients
32in the most cost-effective manner consistent with the delivery
33of quality medical care. To ensure that medical services are
34effectively utilized, the agency may, in any case, require a
35confirmation or second physician's opinion of the correct
36diagnosis for purposes of authorizing future services under the
37Medicaid program. This section does not restrict access to
38emergency services or poststabilization care services as defined
39in 42 C.F.R. part 438.114. Such confirmation or second opinion
40shall be rendered in a manner approved by the agency. The agency
41shall maximize the use of prepaid per capita and prepaid
42aggregate fixed-sum basis services when appropriate and other
43alternative service delivery and reimbursement methodologies,
44including competitive bidding pursuant to s. 287.057, designed
45to facilitate the cost-effective purchase of a case-managed
46continuum of care. The agency shall also require providers to
47minimize the exposure of recipients to the need for acute
48inpatient, custodial, and other institutional care and the
49inappropriate or unnecessary use of high-cost services. The
50agency shall contract with a vendor to monitor and evaluate the
51clinical practice patterns of providers in order to identify
52trends that are outside the normal practice patterns of a
53provider's professional peers or the national guidelines of a
54provider's professional association. The vendor must be able to
55provide information and counseling to a provider whose practice
56patterns are outside the norms, in consultation with the agency,
57to improve patient care and reduce inappropriate utilization.
58The agency may mandate prior authorization, drug therapy
59management, or disease management participation for certain
60populations of Medicaid beneficiaries, certain drug classes, or
61particular drugs to prevent fraud, abuse, overuse, and possible
62dangerous drug interactions. The Pharmaceutical and Therapeutics
63Committee shall make recommendations to the agency on drugs for
64which prior authorization is required. The agency shall inform
65the Pharmaceutical and Therapeutics Committee of its decisions
66regarding drugs subject to prior authorization. The agency is
67authorized to limit the entities it contracts with or enrolls as
68Medicaid providers by developing a provider network through
69provider credentialing. The agency may competitively bid single-
70source-provider contracts if procurement of goods or services
71results in demonstrated cost savings to the state without
72limiting access to care. The agency may limit its network based
73on the assessment of beneficiary access to care, provider
74availability, provider quality standards, time and distance
75standards for access to care, the cultural competence of the
76provider network, demographic characteristics of Medicaid
77beneficiaries, practice and provider-to-beneficiary standards,
78appointment wait times, beneficiary use of services, provider
79turnover, provider profiling, provider licensure history,
80previous program integrity investigations and findings, peer
81review, provider Medicaid policy and billing compliance records,
82clinical and medical record audits, and other factors. Providers
83shall not be entitled to enrollment in the Medicaid provider
84network. The agency shall determine instances in which allowing
85Medicaid beneficiaries to purchase durable medical equipment and
86other goods is less expensive to the Medicaid program than long-
87term rental of the equipment or goods. The agency may establish
88rules to facilitate purchases in lieu of long-term rentals in
89order to protect against fraud and abuse in the Medicaid program
90as defined in s. 409.913. The agency may seek federal waivers
91necessary to administer these policies.
92     (3)  The agency may contract with health maintenance
93organizations certified pursuant to part I of chapter 641 for
94the provision of services to recipients. Any such contract must
95set rates on a beneficiary-specific, risk-adjusted basis, based
96on the beneficiary's age, geographic area, eligibility category,
97gender, prior use of services, diagnoses, and prescription use,
98consistent with the methodology established for the reform areas
99referenced in s. 409.91211.
100     (4)  The agency may contract with:
101     (a)  An entity that provides no prepaid health care
102services other than Medicaid services under contract with the
103agency and which is owned and operated by a county, county
104health department, or county-owned and operated hospital to
105provide health care services on a prepaid or fixed-sum basis to
106recipients, which entity may provide such prepaid services
107either directly or through arrangements with other providers.
108Such prepaid health care services entities must be licensed
109under parts I and III of chapter 641. An entity recognized under
110this paragraph which demonstrates to the satisfaction of the
111Office of Insurance Regulation of the Financial Services
112Commission that it is backed by the full faith and credit of the
113county in which it is located may be exempted from s. 641.225.
114Any contract with an entity described in this paragraph must set
115rates on a beneficiary-specific, risk-adjusted basis based on
116the beneficiary's age, geographic area, eligibility category,
117gender, prior use of services, diagnoses, and prescription use,
118consistent with the methodology established for the reform areas
119referenced in s. 409.91211.
120     (b)  An entity that is providing comprehensive behavioral
121health care services to certain Medicaid recipients through a
122capitated, prepaid arrangement pursuant to the federal waiver
123provided for by s. 409.905(5). Such an entity must be licensed
124under chapter 624, chapter 636, or chapter 641 and must possess
125the clinical systems and operational competence to manage risk
126and provide comprehensive behavioral health care to Medicaid
127recipients. As used in this paragraph, the term "comprehensive
128behavioral health care services" means covered mental health and
129substance abuse treatment services that are available to
130Medicaid recipients. The secretary of the Department of Children
131and Family Services shall approve provisions of procurements
132related to children in the department's care or custody prior to
133enrolling such children in a prepaid behavioral health plan. Any
134contract awarded under this paragraph must be competitively
135procured. In developing the behavioral health care prepaid plan
136procurement document, the agency shall ensure that the
137procurement document requires the contractor to develop and
138implement a plan to ensure compliance with s. 394.4574 related
139to services provided to residents of licensed assisted living
140facilities that hold a limited mental health license. Except as
141provided in subparagraph 8., and except in counties where the
142Medicaid managed care pilot program is authorized pursuant to s.
143409.91211, the agency shall seek federal approval to contract
144with a single entity meeting these requirements to provide
145comprehensive behavioral health care services to all Medicaid
146recipients not enrolled in a Medicaid managed care plan
147authorized under s. 409.91211 or a Medicaid health maintenance
148organization in an AHCA area. In an AHCA area where the Medicaid
149managed care pilot program is authorized pursuant to s.
150409.91211 in one or more counties, the agency may procure a
151contract with a single entity to serve the remaining counties as
152an AHCA area or the remaining counties may be included with an
153adjacent AHCA area and shall be subject to this paragraph. Each
154entity must offer sufficient choice of providers in its network
155to ensure recipient access to care and the opportunity to select
156a provider with whom they are satisfied. The network shall
157include all public mental health hospitals. To ensure unimpaired
158access to behavioral health care services by Medicaid
159recipients, all contracts issued pursuant to this paragraph
160shall require 80 percent of the capitation paid to the managed
161care plan, including health maintenance organizations, to be
162expended for the provision of behavioral health care services.
163In the event the managed care plan expends less than 80 percent
164of the capitation paid pursuant to this paragraph for the
165provision of behavioral health care services, the difference
166shall be returned to the agency. The agency shall provide the
167managed care plan with a certification letter indicating the
168amount of capitation paid during each calendar year for the
169provision of behavioral health care services pursuant to this
170section. Any funds repaid to the agency by a managed care plan
171that fails to meet the 80-percent requirement shall be deposited
172into a trust fund by the agency and transferred to the
173Department of Children and Family Services for reinvestment in
174community health services provided by providers enrolled in the
175networks of managed care plans that failed to the meet the 80-
176percent requirement. The agency shall assess interest and fines
177on the amounts below the 80-percent threshold. The agency may
178reimburse for substance abuse treatment services on a fee-for-
179service basis until the agency finds that adequate funds are
180available for capitated, prepaid arrangements. The agency shall
181continue to offer beneficiaries a choice of and contract with
182prepaid mental health plans as long as the agency operates its
183MediPass program. However, beneficiaries enrolled in MediPass
184may not be enrolled in a health maintenance organization for
185behavioral health services.
186     1.  By January 1, 2001, the agency shall modify the
187contracts with the entities providing comprehensive inpatient
188and outpatient mental health care services to Medicaid
189recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
190Counties, to include substance abuse treatment services.
191     2.  By July 1, 2003, the agency and the Department of
192Children and Family Services shall execute a written agreement
193that requires collaboration and joint development of all policy,
194budgets, procurement documents, contracts, and monitoring plans
195that have an impact on the state and Medicaid community mental
196health and targeted case management programs.
197     3.  Except as provided in subparagraph 8., by July 1, 2006,
198the agency and the Department of Children and Family Services
199shall contract with managed care entities in each AHCA area
200except area 6 or arrange to provide comprehensive inpatient and
201outpatient mental health and substance abuse services through
202capitated prepaid arrangements to all Medicaid recipients who
203are eligible to participate in such plans under federal law and
204regulation. In AHCA areas where eligible individuals number less
205than 150,000, the agency shall contract with a single managed
206care plan to provide comprehensive behavioral health services to
207all recipients who are not enrolled in a Medicaid health
208maintenance organization or a Medicaid capitated managed care
209plan authorized under s. 409.91211. The agency may contract with
210more than one comprehensive behavioral health provider to
211provide care to recipients who are not enrolled in a Medicaid
212capitated managed care plan authorized under s. 409.91211 or a
213Medicaid health maintenance organization in AHCA areas where the
214eligible population exceeds 150,000. In an AHCA area where the
215Medicaid managed care pilot program is authorized pursuant to s.
216409.91211 in one or more counties, the agency may procure a
217contract with a single entity to serve the remaining counties as
218an AHCA area or the remaining counties may be included with an
219adjacent AHCA area and shall be subject to this paragraph.
220Contracts for comprehensive behavioral health providers awarded
221pursuant to this section shall be competitively procured. Both
222for-profit and not-for-profit corporations shall be eligible to
223compete. Managed care plans contracting with the agency under
224subsection (3) shall provide and receive payment for the same
225comprehensive behavioral health benefits as provided in AHCA
226rules, including handbooks incorporated by reference. In AHCA
227area 11, the agency shall contract with at least two
228comprehensive behavioral health care providers to provide
229behavioral health care to recipients in that area who are
230enrolled in, or assigned to, the MediPass program. One of the
231behavioral health care contracts shall be with the existing
232provider service network pilot project, as described in
233paragraph (d), for the purpose of demonstrating the cost-
234effectiveness of the provision of quality mental health services
235through a public hospital-operated managed care model. Payment
236shall be at an agreed-upon capitated rate to ensure cost
237savings. Of the recipients in area 11 who are assigned to
238MediPass under the provisions of s. 409.9122(2)(k), a minimum of
23950,000 of those MediPass-enrolled recipients shall be assigned
240to the existing provider service network in area 11 for their
241behavioral care.
242     4.  By October 1, 2003, the agency and the department shall
243submit a plan to the Governor, the President of the Senate, and
244the Speaker of the House of Representatives which provides for
245the full implementation of capitated prepaid behavioral health
246care in all areas of the state.
247     a.  Implementation shall begin in 2003 in those AHCA areas
248of the state where the agency is able to establish sufficient
249capitation rates.
250     b.  If the agency determines that the proposed capitation
251rate in any area is insufficient to provide appropriate
252services, the agency may adjust the capitation rate to ensure
253that care will be available. The agency and the department may
254use existing general revenue to address any additional required
255match but may not over-obligate existing funds on an annualized
256basis.
257     c.  Subject to any limitations provided for in the General
258Appropriations Act, the agency, in compliance with appropriate
259federal authorization, shall develop policies and procedures
260that allow for certification of local and state funds.
261     5.  Children residing in a statewide inpatient psychiatric
262program, or in a Department of Juvenile Justice or a Department
263of Children and Family Services residential program approved as
264a Medicaid behavioral health overlay services provider shall not
265be included in a behavioral health care prepaid health plan or
266any other Medicaid managed care plan pursuant to this paragraph.
267     6.  In converting to a prepaid system of delivery, the
268agency shall in its procurement document require an entity
269providing only comprehensive behavioral health care services to
270prevent the displacement of indigent care patients by enrollees
271in the Medicaid prepaid health plan providing behavioral health
272care services from facilities receiving state funding to provide
273indigent behavioral health care, to facilities licensed under
274chapter 395 which do not receive state funding for indigent
275behavioral health care, or reimburse the unsubsidized facility
276for the cost of behavioral health care provided to the displaced
277indigent care patient.
278     7.  Traditional community mental health providers under
279contract with the Department of Children and Family Services
280pursuant to part IV of chapter 394, child welfare providers
281under contract with the Department of Children and Family
282Services in areas 1 and 6, and inpatient mental health providers
283licensed pursuant to chapter 395 must be offered an opportunity
284to accept or decline a contract to participate in any provider
285network for prepaid behavioral health services.
286     8.  All Medicaid-eligible children, except children in area
2871 and children in Highlands County, Hardee County, Polk County,
288or Manatee County of area 6, who are open for child welfare
289services in the HomeSafeNet system, shall receive their
290behavioral health care services through a specialty prepaid plan
291operated by community-based lead agencies either through a
292single agency or formal agreements among several agencies. The
293specialty prepaid plan must result in savings to the state
294comparable to savings achieved in other Medicaid managed care
295and prepaid programs. Such plan must provide mechanisms to
296maximize state and local revenues. The specialty prepaid plan
297shall be developed by the agency and the Department of Children
298and Family Services. The agency is authorized to seek any
299federal waivers to implement this initiative. Medicaid-eligible
300children whose cases are open for child welfare services in the
301HomeSafeNet system and who reside in AHCA area 10 are exempt
302from the specialty prepaid plan upon the development of a
303service delivery mechanism for children who reside in area 10 as
304specified in s. 409.91211(3)(dd).
305     Section 2.  Paragraph (w) of subsection (3) of section
306409.91211, Florida Statutes, is amended to read:
307     409.91211  Medicaid managed care pilot program.--
308     (3)  The agency shall have the following powers, duties,
309and responsibilities with respect to the pilot program:
310     (w)  To implement procedures to minimize the risk of
311Medicaid fraud and abuse in all plans operating in the Medicaid
312managed care pilot program authorized in this section.
313     1.  The agency shall ensure that applicable provisions of
314this chapter and chapters 414, 626, 641, and 932 which relate to
315Medicaid fraud and abuse are applied and enforced at the
316demonstration project sites.
317     2.  Providers must have the certification, license, and
318credentials that are required by law and waiver requirements.
319     3.  The agency shall ensure that the plan is in compliance
320with s. 409.912(4)(b), (21), s. 409.912(21) and (22).
321     4.  The agency shall require that each plan establish
322functions and activities governing program integrity in order to
323reduce the incidence of fraud and abuse. Plans must report
324instances of fraud and abuse pursuant to chapter 641.
325     5.  The plan shall have written administrative and
326management arrangements or procedures, including a mandatory
327compliance plan, which are designed to guard against fraud and
328abuse. The plan shall designate a compliance officer who has
329sufficient experience in health care.
330     6.a.  The agency shall require all managed care plan
331contractors in the pilot program to report all instances of
332suspected fraud and abuse. A failure to report instances of
333suspected fraud and abuse is a violation of law and subject to
334the penalties provided by law.
335     b.  An instance of fraud and abuse in the managed care
336plan, including, but not limited to, defrauding the state health
337care benefit program by misrepresentation of fact in reports,
338claims, certifications, enrollment claims, demographic
339statistics, or patient-encounter data; misrepresentation of the
340qualifications of persons rendering health care and ancillary
341services; bribery and false statements relating to the delivery
342of health care; unfair and deceptive marketing practices; and
343false claims actions in the provision of managed care, is a
344violation of law and subject to the penalties provided by law.
345     c.  The agency shall require that all contractors make all
346files and relevant billing and claims data accessible to state
347regulators and investigators and that all such data is linked
348into a unified system to ensure consistent reviews and
349investigations.
350     Section 3.  Paragraph (i) of subsection (2) of section
351409.9122, Florida Statutes, is amended to read:
352     409.9122  Mandatory Medicaid managed care enrollment;
353programs and procedures.--
354     (2)
355     (i)  After a recipient has made his or her selection or has
356been enrolled in a managed care plan or MediPass, the recipient
357shall have 90 days to exercise the opportunity to voluntarily
358disenroll and select another managed care plan or MediPass.
359After 90 days, no further changes may be made except for good
360cause. Good cause includes, but is not limited to, poor quality
361of care, lack of access to necessary specialty services, an
362unreasonable delay or denial of service, mental illness of the
363recipient, or fraudulent enrollment. The agency shall develop
364criteria for good cause disenrollment for chronically ill and
365disabled populations who are assigned to managed care plans if
366more appropriate care is available through the MediPass program.
367The agency must make a determination as to whether cause exists.
368However, the agency may require a recipient to use the managed
369care plan's or MediPass grievance process prior to the agency's
370determination of cause, except in cases in which immediate risk
371of permanent damage to the recipient's health is alleged. The
372grievance process, when utilized, must be completed in time to
373permit the recipient to disenroll by the first day of the second
374month after the month the disenrollment request was made. If the
375managed care plan or MediPass, as a result of the grievance
376process, approves an enrollee's request to disenroll, the agency
377is not required to make a determination in the case. The agency
378must make a determination and take final action on a recipient's
379request so that disenrollment occurs no later than the first day
380of the second month after the month the request was made. If the
381agency fails to act within the specified timeframe, the
382recipient's request to disenroll is deemed to be approved as of
383the date agency action was required. Recipients who disagree
384with the agency's finding that cause does not exist for
385disenrollment shall be advised of their right to pursue a
386Medicaid fair hearing to dispute the agency's finding.
387     Section 4.  This act shall take effect upon becoming a law.


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