Florida Senate - 2009 SB 2422
By Senator Storms
10-00328A-09 20092422__
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.912,
3 F.S.; requiring a contract between the Agency for
4 Health Care Administration and certain health
5 maintenance organizations or entities that do not
6 provide prepaid health care services to set rates on a
7 beneficiary-specific, risk-adjusted basis; requiring
8 that funds repaid to the agency by managed care plans
9 that spend less than a certain percentage of the
10 capitation paid to the plan to be deposited into a
11 trust fund by the agency and transferred to the
12 Department of Children and Family Services; requiring
13 the agency to assess interest and fines; requiring the
14 agency to continue to offer beneficiaries a choice of
15 and contract with prepaid mental health plans under
16 certain conditions; prohibiting MediPass beneficiaries
17 from enrolling in a health maintenance organization
18 for behavioral health services; amending s. 409.91211,
19 F.S.; conforming a provision to changes made by the
20 act; amending s. 409.9122, F.S.; providing that mental
21 illness is a showing of good cause to allow a Medicaid
22 recipient to disenroll and select another managed care
23 plan or MediPass after a specified period of time;
24 providing an effective date.
25
26 Be It Enacted by the Legislature of the State of Florida:
27
28 Section 1. Subsection (3) and paragraphs (a) and (b) of
29 subsection (4) of section 409.912, Florida Statutes, are amended
30 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
34 of 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
46 to 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.
59 The agency may mandate prior authorization, drug therapy
60 management, or disease management participation for certain
61 populations of Medicaid beneficiaries, certain drug classes, or
62 particular drugs to prevent fraud, abuse, overuse, and possible
63 dangerous drug interactions. The Pharmaceutical and Therapeutics
64 Committee shall make recommendations to the agency on drugs for
65 which prior authorization is required. The agency shall inform
66 the 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 (3) The agency may contract with health maintenance
94 organizations certified pursuant to part I of chapter 641 for
95 the provision of services to recipients. Any such contract must
96 set rates on a beneficiary-specific, risk-adjusted basis, based
97 on the beneficiary's age, geographic area, eligibility category,
98 gender, prior use of services, diagnoses, and prescription use,
99 consistent with the methodology established for the reform areas
100 referenced in s. 409.91211.
101 (4) The agency may contract with:
102 (a) An entity that provides no prepaid health care services
103 other than Medicaid services under contract with the agency and
104 which is owned and operated by a county, county health
105 department, or county-owned and operated hospital to provide
106 health care services on a prepaid or fixed-sum basis to
107 recipients, which entity may provide such prepaid services
108 either directly or through arrangements with other providers.
109 Such prepaid health care services entities must be licensed
110 under parts I and III of chapter 641. An entity recognized under
111 this paragraph which demonstrates to the satisfaction of the
112 Office of Insurance Regulation of the Financial Services
113 Commission that it is backed by the full faith and credit of the
114 county in which it is located may be exempted from s. 641.225.
115 Any contract with an entity described in this paragraph must set
116 rates on a beneficiary-specific, risk-adjusted basis based on
117 the beneficiary's age, geographic area, eligibility category,
118 gender, prior use of services, diagnoses, and prescription use,
119 consistent with the methodology established for the reform areas
120 referenced in s. 409.91211.
121 (b) An entity that is providing comprehensive behavioral
122 health care services to certain Medicaid recipients through a
123 capitated, prepaid arrangement pursuant to the federal waiver
124 provided for by s. 409.905(5). Such an entity must be licensed
125 under chapter 624, chapter 636, or chapter 641 and must possess
126 the clinical systems and operational competence to manage risk
127 and provide comprehensive behavioral health care to Medicaid
128 recipients. As used in this paragraph, the term “comprehensive
129 behavioral health care services” means covered mental health and
130 substance abuse treatment services that are available to
131 Medicaid recipients. The secretary of the Department of Children
132 and Family Services shall approve provisions of procurements
133 related to children in the department's care or custody prior to
134 enrolling such children in a prepaid behavioral health plan. Any
135 contract awarded under this paragraph must be competitively
136 procured. In developing the behavioral health care prepaid plan
137 procurement document, the agency shall ensure that the
138 procurement document requires the contractor to develop and
139 implement a plan to ensure compliance with s. 394.4574 related
140 to services provided to residents of licensed assisted living
141 facilities that hold a limited mental health license. Except as
142 provided in subparagraph 8., and except in counties where the
143 Medicaid managed care pilot program is authorized pursuant to s.
144 409.91211, the agency shall seek federal approval to contract
145 with a single entity meeting these requirements to provide
146 comprehensive behavioral health care services to all Medicaid
147 recipients not enrolled in a Medicaid managed care plan
148 authorized under s. 409.91211 or a Medicaid health maintenance
149 organization in an AHCA area. In an AHCA area where the Medicaid
150 managed care pilot program is authorized pursuant to s.
151 409.91211 in one or more counties, the agency may procure a
152 contract with a single entity to serve the remaining counties as
153 an AHCA area or the remaining counties may be included with an
154 adjacent AHCA area and shall be subject to this paragraph. Each
155 entity must offer sufficient choice of providers in its network
156 to ensure recipient access to care and the opportunity to select
157 a provider with whom they are satisfied. The network shall
158 include all public mental health hospitals. To ensure unimpaired
159 access to behavioral health care services by Medicaid
160 recipients, all contracts issued pursuant to this paragraph
161 shall require 80 percent of the capitation paid to the managed
162 care plan, including health maintenance organizations, to be
163 expended for the provision of behavioral health care services.
164 In the event the managed care plan expends less than 80 percent
165 of the capitation paid pursuant to this paragraph for the
166 provision of behavioral health care services, the difference
167 shall be returned to the agency. The agency shall provide the
168 managed care plan with a certification letter indicating the
169 amount of capitation paid during each calendar year for the
170 provision of behavioral health care services pursuant to this
171 section. Any funds repaid to the agency by a managed care plan
172 that fails to meet the 80-percent requirement shall be deposited
173 into a trust fund by the agency and transferred to the
174 Department of Children and Family Services for reinvestment in
175 community health services provided by providers enrolled in the
176 networks of managed care plans that failed to the meet the 80
177 percent requirement. The agency shall assess interest and fines
178 on the amounts below the 80-percent threshold. The agency may
179 reimburse for substance abuse treatment services on a fee-for
180 service basis until the agency finds that adequate funds are
181 available for capitated, prepaid arrangements. The agency shall
182 continue to offer beneficiaries a choice of and contract with
183 prepaid mental health plans as long as the agency operates its
184 MediPass program. However, beneficiaries enrolled in MediPass
185 may not be enrolled in a health maintenance organization for
186 behavioral health services.
187 1. By January 1, 2001, the agency shall modify the
188 contracts with the entities providing comprehensive inpatient
189 and outpatient mental health care services to Medicaid
190 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
191 Counties, to include substance abuse treatment services.
192 2. By July 1, 2003, the agency and the Department of
193 Children and Family Services shall execute a written agreement
194 that requires collaboration and joint development of all policy,
195 budgets, procurement documents, contracts, and monitoring plans
196 that have an impact on the state and Medicaid community mental
197 health and targeted case management programs.
198 3. Except as provided in subparagraph 8., by July 1, 2006,
199 the agency and the Department of Children and Family Services
200 shall contract with managed care entities in each AHCA area
201 except area 6 or arrange to provide comprehensive inpatient and
202 outpatient mental health and substance abuse services through
203 capitated prepaid arrangements to all Medicaid recipients who
204 are eligible to participate in such plans under federal law and
205 regulation. In AHCA areas where eligible individuals number less
206 than 150,000, the agency shall contract with a single managed
207 care plan to provide comprehensive behavioral health services to
208 all recipients who are not enrolled in a Medicaid health
209 maintenance organization or a Medicaid capitated managed care
210 plan authorized under s. 409.91211. The agency may contract with
211 more than one comprehensive behavioral health provider to
212 provide care to recipients who are not enrolled in a Medicaid
213 capitated managed care plan authorized under s. 409.91211 or a
214 Medicaid health maintenance organization in AHCA areas where the
215 eligible population exceeds 150,000. In an AHCA area where the
216 Medicaid managed care pilot program is authorized pursuant to s.
217 409.91211 in one or more counties, the agency may procure a
218 contract with a single entity to serve the remaining counties as
219 an AHCA area or the remaining counties may be included with an
220 adjacent AHCA area and shall be subject to this paragraph.
221 Contracts for comprehensive behavioral health providers awarded
222 pursuant to this section shall be competitively procured. Both
223 for-profit and not-for-profit corporations shall be eligible to
224 compete. Managed care plans contracting with the agency under
225 subsection (3) shall provide and receive payment for the same
226 comprehensive behavioral health benefits as provided in AHCA
227 rules, including handbooks incorporated by reference. In AHCA
228 area 11, the agency shall contract with at least two
229 comprehensive behavioral health care providers to provide
230 behavioral health care to recipients in that area who are
231 enrolled in, or assigned to, the MediPass program. One of the
232 behavioral health care contracts shall be with the existing
233 provider service network pilot project, as described in
234 paragraph (d), for the purpose of demonstrating the cost
235 effectiveness of the provision of quality mental health services
236 through a public hospital-operated managed care model. Payment
237 shall be at an agreed-upon capitated rate to ensure cost
238 savings. Of the recipients in area 11 who are assigned to
239 MediPass under the provisions of s. 409.9122(2)(k), a minimum of
240 50,000 of those MediPass-enrolled recipients shall be assigned
241 to the existing provider service network in area 11 for their
242 behavioral care.
243 4. By October 1, 2003, the agency and the department shall
244 submit a plan to the Governor, the President of the Senate, and
245 the Speaker of the House of Representatives which provides for
246 the full implementation of capitated prepaid behavioral health
247 care in all areas of the state.
248 a. Implementation shall begin in 2003 in those AHCA areas
249 of the state where the agency is able to establish sufficient
250 capitation rates.
251 b. If the agency determines that the proposed capitation
252 rate in any area is insufficient to provide appropriate
253 services, the agency may adjust the capitation rate to ensure
254 that care will be available. The agency and the department may
255 use existing general revenue to address any additional required
256 match but may not over-obligate existing funds on an annualized
257 basis.
258 c. Subject to any limitations provided for in the General
259 Appropriations Act, the agency, in compliance with appropriate
260 federal authorization, shall develop policies and procedures
261 that allow for certification of local and state funds.
262 5. Children residing in a statewide inpatient psychiatric
263 program, or in a Department of Juvenile Justice or a Department
264 of Children and Family Services residential program approved as
265 a Medicaid behavioral health overlay services provider shall not
266 be included in a behavioral health care prepaid health plan or
267 any other Medicaid managed care plan pursuant to this paragraph.
268 6. In converting to a prepaid system of delivery, the
269 agency shall in its procurement document require an entity
270 providing only comprehensive behavioral health care services to
271 prevent the displacement of indigent care patients by enrollees
272 in the Medicaid prepaid health plan providing behavioral health
273 care services from facilities receiving state funding to provide
274 indigent behavioral health care, to facilities licensed under
275 chapter 395 which do not receive state funding for indigent
276 behavioral health care, or reimburse the unsubsidized facility
277 for the cost of behavioral health care provided to the displaced
278 indigent care patient.
279 7. Traditional community mental health providers under
280 contract with the Department of Children and Family Services
281 pursuant to part IV of chapter 394, child welfare providers
282 under contract with the Department of Children and Family
283 Services in areas 1 and 6, and inpatient mental health providers
284 licensed pursuant to chapter 395 must be offered an opportunity
285 to accept or decline a contract to participate in any provider
286 network for prepaid behavioral health services.
287 8. All Medicaid-eligible children, except children in area
288 1 and children in Highlands County, Hardee County, Polk County,
289 or Manatee County of area 6, who are open for child welfare
290 services in the HomeSafeNet system, shall receive their
291 behavioral health care services through a specialty prepaid plan
292 operated by community-based lead agencies either through a
293 single agency or formal agreements among several agencies. The
294 specialty prepaid plan must result in savings to the state
295 comparable to savings achieved in other Medicaid managed care
296 and prepaid programs. Such plan must provide mechanisms to
297 maximize state and local revenues. The specialty prepaid plan
298 shall be developed by the agency and the Department of Children
299 and Family Services. The agency is authorized to seek any
300 federal waivers to implement this initiative. Medicaid-eligible
301 children whose cases are open for child welfare services in the
302 HomeSafeNet system and who reside in AHCA area 10 are exempt
303 from the specialty prepaid plan upon the development of a
304 service delivery mechanism for children who reside in area 10 as
305 specified in s. 409.91211(3)(dd).
306 Section 2. Paragraph (w) of subsection (3) of section
307 409.91211, Florida Statutes, is amended to read:
308 409.91211 Medicaid managed care pilot program.—
309 (3) The agency shall have the following powers, duties, and
310 responsibilities with respect to the pilot program:
311 (w) To implement procedures to minimize the risk of
312 Medicaid fraud and abuse in all plans operating in the Medicaid
313 managed care pilot program authorized in this section.
314 1. The agency shall ensure that applicable provisions of
315 this chapter and chapters 414, 626, 641, and 932 which relate to
316 Medicaid fraud and abuse are applied and enforced at the
317 demonstration project sites.
318 2. Providers must have the certification, license, and
319 credentials that are required by law and waiver requirements.
320 3. The agency shall ensure that the plan is in compliance
321 with s. 409.912(4)(b), (21), s. 409.912(21) and (22).
322 4. The agency shall require that each plan establish
323 functions and activities governing program integrity in order to
324 reduce the incidence of fraud and abuse. Plans must report
325 instances of fraud and abuse pursuant to chapter 641.
326 5. The plan shall have written administrative and
327 management arrangements or procedures, including a mandatory
328 compliance plan, which are designed to guard against fraud and
329 abuse. The plan shall designate a compliance officer who has
330 sufficient experience in health care.
331 6.a. The agency shall require all managed care plan
332 contractors in the pilot program to report all instances of
333 suspected fraud and abuse. A failure to report instances of
334 suspected fraud and abuse is a violation of law and subject to
335 the penalties provided by law.
336 b. An instance of fraud and abuse in the managed care plan,
337 including, but not limited to, defrauding the state health care
338 benefit program by misrepresentation of fact in reports, claims,
339 certifications, enrollment claims, demographic statistics, or
340 patient-encounter data; misrepresentation of the qualifications
341 of persons rendering health care and ancillary services; bribery
342 and false statements relating to the delivery of health care;
343 unfair and deceptive marketing practices; and false claims
344 actions in the provision of managed care, is a violation of law
345 and subject to the penalties provided by law.
346 c. The agency shall require that all contractors make all
347 files and relevant billing and claims data accessible to state
348 regulators and investigators and that all such data is linked
349 into a unified system to ensure consistent reviews and
350 investigations.
351 Section 3. Paragraph (i) of subsection (2) of section
352 409.9122, Florida Statutes, is amended to read:
353 409.9122 Mandatory Medicaid managed care enrollment;
354 programs and procedures.—
355 (2)
356 (i) After a recipient has made his or her selection or has
357 been enrolled in a managed care plan or MediPass, the recipient
358 shall have 90 days to exercise the opportunity to voluntarily
359 disenroll and select another managed care plan or MediPass.
360 After 90 days, no further changes may be made except for good
361 cause. Good cause includes, but is not limited to, poor quality
362 of care, lack of access to necessary specialty services, an
363 unreasonable delay or denial of service, mental illness of the
364 recipient, or fraudulent enrollment. The agency shall develop
365 criteria for good cause disenrollment for chronically ill and
366 disabled populations who are assigned to managed care plans if
367 more appropriate care is available through the MediPass program.
368 The agency must make a determination as to whether cause exists.
369 However, the agency may require a recipient to use the managed
370 care plan's or MediPass grievance process prior to the agency's
371 determination of cause, except in cases in which immediate risk
372 of permanent damage to the recipient's health is alleged. The
373 grievance process, when utilized, must be completed in time to
374 permit the recipient to disenroll by the first day of the second
375 month after the month the disenrollment request was made. If the
376 managed care plan or MediPass, as a result of the grievance
377 process, approves an enrollee's request to disenroll, the agency
378 is not required to make a determination in the case. The agency
379 must make a determination and take final action on a recipient's
380 request so that disenrollment occurs no later than the first day
381 of the second month after the month the request was made. If the
382 agency fails to act within the specified timeframe, the
383 recipient's request to disenroll is deemed to be approved as of
384 the date agency action was required. Recipients who disagree
385 with the agency's finding that cause does not exist for
386 disenrollment shall be advised of their right to pursue a
387 Medicaid fair hearing to dispute the agency's finding.
388 Section 4. This act shall take effect upon becoming a law.