Florida Senate - 2009 CS for CS for SB 2422
By the Committees on Children, Families, and Elder Affairs; and
Health Regulation; and Senator Storms
586-04467-09 20092422c2
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.91195,
3 F.S.; revising the membership of the Medicaid
4 Pharmaceutical and Therapeutics Committee within the
5 Agency for Health Care Administration to include a
6 member who is enrolled in the Medicaid program;
7 amending s. 409.912, F.S.; requiring that funds repaid
8 to the agency by managed care plans that spend less
9 than a certain percentage of the capitation rate for
10 behavioral health services be deposited into the
11 Medical Care Trust Fund; providing that such
12 repayments be allocated to community behavioral health
13 providers and used for Medicaid behavioral and case
14 management services; amending s. 409.9122, F.S.;
15 revising the criteria for good-cause disenrollment in
16 a managed care plan or Medipass; providing an
17 effective date.
18
19 Be It Enacted by the Legislature of the State of Florida:
20
21 Section 1. Subsection (1) of section 409.91195, Florida
22 Statutes, is amended to read:
23 409.91195 Medicaid Pharmaceutical and Therapeutics
24 Committee.—There is created a Medicaid Pharmaceutical and
25 Therapeutics Committee within the agency for the purpose of
26 developing a Medicaid preferred drug list.
27 (1) The committee shall be composed of 11 members appointed
28 by the Governor. Four members shall be physicians, licensed
29 under chapter 458; one member licensed under chapter 459; five
30 members shall be pharmacists licensed under chapter 465; and one
31 member shall be a consumer representative who is enrolled in the
32 Medicaid program. The members shall be appointed to serve for
33 terms of 2 years from the date of their appointment. Members may
34 be appointed to more than one term. The agency shall serve as
35 staff for the committee and assist them with all ministerial
36 duties. The Governor shall ensure that at least some of the
37 members of the committee represent Medicaid participating
38 physicians and pharmacies serving all segments and diversity of
39 the Medicaid population, and have experience in either
40 developing or practicing under a preferred drug list. At least
41 one of the members shall represent the interests of
42 pharmaceutical manufacturers.
43 Section 2. Paragraph (b) of subsection (4) of section
44 409.912, Florida Statutes, is amended to read:
45 409.912 Cost-effective purchasing of health care.—The
46 agency shall purchase goods and services for Medicaid recipients
47 in the most cost-effective manner consistent with the delivery
48 of quality medical care. To ensure that medical services are
49 effectively utilized, the agency may, in any case, require a
50 confirmation or second physician’s opinion of the correct
51 diagnosis for purposes of authorizing future services under the
52 Medicaid program. This section does not restrict access to
53 emergency services or poststabilization care services as defined
54 in 42 C.F.R. part 438.114. Such confirmation or second opinion
55 shall be rendered in a manner approved by the agency. The agency
56 shall maximize the use of prepaid per capita and prepaid
57 aggregate fixed-sum basis services when appropriate and other
58 alternative service delivery and reimbursement methodologies,
59 including competitive bidding pursuant to s. 287.057, designed
60 to facilitate the cost-effective purchase of a case-managed
61 continuum of care. The agency shall also require providers to
62 minimize the exposure of recipients to the need for acute
63 inpatient, custodial, and other institutional care and the
64 inappropriate or unnecessary use of high-cost services. The
65 agency shall contract with a vendor to monitor and evaluate the
66 clinical practice patterns of providers in order to identify
67 trends that are outside the normal practice patterns of a
68 provider’s professional peers or the national guidelines of a
69 provider’s professional association. The vendor must be able to
70 provide information and counseling to a provider whose practice
71 patterns are outside the norms, in consultation with the agency,
72 to improve patient care and reduce inappropriate utilization.
73 The agency may mandate prior authorization, drug therapy
74 management, or disease management participation for certain
75 populations of Medicaid beneficiaries, certain drug classes, or
76 particular drugs to prevent fraud, abuse, overuse, and possible
77 dangerous drug interactions. The Pharmaceutical and Therapeutics
78 Committee shall make recommendations to the agency on drugs for
79 which prior authorization is required. The agency shall inform
80 the Pharmaceutical and Therapeutics Committee of its decisions
81 regarding drugs subject to prior authorization. The agency is
82 authorized to limit the entities it contracts with or enrolls as
83 Medicaid providers by developing a provider network through
84 provider credentialing. The agency may competitively bid single
85 source-provider contracts if procurement of goods or services
86 results in demonstrated cost savings to the state without
87 limiting access to care. The agency may limit its network based
88 on the assessment of beneficiary access to care, provider
89 availability, provider quality standards, time and distance
90 standards for access to care, the cultural competence of the
91 provider network, demographic characteristics of Medicaid
92 beneficiaries, practice and provider-to-beneficiary standards,
93 appointment wait times, beneficiary use of services, provider
94 turnover, provider profiling, provider licensure history,
95 previous program integrity investigations and findings, peer
96 review, provider Medicaid policy and billing compliance records,
97 clinical and medical record audits, and other factors. Providers
98 shall not be entitled to enrollment in the Medicaid provider
99 network. The agency shall determine instances in which allowing
100 Medicaid beneficiaries to purchase durable medical equipment and
101 other goods is less expensive to the Medicaid program than long
102 term rental of the equipment or goods. The agency may establish
103 rules to facilitate purchases in lieu of long-term rentals in
104 order to protect against fraud and abuse in the Medicaid program
105 as defined in s. 409.913. The agency may seek federal waivers
106 necessary to administer these policies.
107 (4) The agency may contract with:
108 (b) An entity that is providing comprehensive behavioral
109 health care services to certain Medicaid recipients through a
110 capitated, prepaid arrangement pursuant to the federal waiver
111 authorized in provided for by s. 409.905(5). Such an entity must
112 be licensed under chapter 624, chapter 636, or chapter 641 and
113 must possess the clinical systems and operational competence to
114 manage risk and provide comprehensive behavioral health care to
115 Medicaid recipients. As used in this paragraph, the term
116 “comprehensive behavioral health care services” means covered
117 mental health and substance abuse treatment services that are
118 available to Medicaid recipients. The secretary of the
119 Department of Children and Family Services must shall approve
120 provisions of procurements related to children in the
121 department’s care or custody before prior to enrolling such
122 children in a prepaid behavioral health plan. Any contract
123 awarded under this paragraph must be competitively procured. In
124 developing the behavioral health care prepaid plan procurement
125 document, the agency shall ensure that the procurement document
126 requires the contractor to develop and implement a plan to
127 ensure compliance with s. 394.4574 related to services provided
128 to residents of licensed assisted living facilities that hold a
129 limited mental health license. Except as provided in
130 subparagraph 8., and except in counties where the Medicaid
131 managed care pilot program is authorized pursuant to s.
132 409.91211, the agency shall seek federal approval to contract
133 with a single entity meeting these requirements to provide
134 comprehensive behavioral health care services to all Medicaid
135 recipients not enrolled in a Medicaid managed care plan
136 authorized under s. 409.91211 or a Medicaid health maintenance
137 organization in an AHCA area. In an AHCA area where the Medicaid
138 managed care pilot program is authorized pursuant to s.
139 409.91211 in one or more counties, the agency may procure a
140 contract with a single entity to serve the remaining counties as
141 an AHCA area or the remaining counties may be included with an
142 adjacent AHCA area and are shall be subject to this paragraph.
143 Each entity must offer a sufficient choice of providers in its
144 network to ensure recipient access to care and the opportunity
145 to select a provider with whom they are satisfied. The network
146 shall include all public mental health hospitals. To ensure
147 unimpaired access to behavioral health care services by Medicaid
148 recipients, all contracts issued pursuant to this paragraph
149 shall require 80 percent of the capitation paid to the managed
150 care plan, including health maintenance organizations, to be
151 expended for the provision of behavioral health care services.
152 In the event the managed care plan expends less than 80 percent
153 of the capitation paid pursuant to this paragraph for the
154 provision of behavioral health care services, the difference
155 shall be returned to the agency. The agency shall provide the
156 managed care plan with a certification letter indicating the
157 amount of capitation paid during each calendar year for the
158 provision of behavioral health care services pursuant to this
159 section. The agency may reimburse for substance abuse treatment
160 services on a fee-for-service basis until the agency finds that
161 adequate funds are available for capitated, prepaid
162 arrangements.
163 1. By January 1, 2001, the agency shall modify the
164 contracts with the entities providing comprehensive inpatient
165 and outpatient mental health care services to Medicaid
166 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
167 Counties, to include substance abuse treatment services.
168 2. By July 1, 2003, the agency and the department of
169 Children and Family Services shall execute a written agreement
170 that requires collaboration and joint development of all policy,
171 budgets, procurement documents, contracts, and monitoring plans
172 that have an impact on the state and Medicaid community mental
173 health and targeted case management programs.
174 3. Except as provided in subparagraph 8., by July 1, 2006,
175 the agency and the department of Children and Family Services
176 shall contract with managed care entities in each AHCA area
177 except area 6 or arrange to provide comprehensive inpatient and
178 outpatient mental health and substance abuse services through
179 capitated prepaid arrangements to all Medicaid recipients who
180 are eligible to participate in such plans under federal law and
181 regulation. In AHCA areas where eligible individuals number less
182 than 150,000, the agency shall contract with a single managed
183 care plan to provide comprehensive behavioral health services to
184 all recipients who are not enrolled in a Medicaid health
185 maintenance organization or a Medicaid capitated managed care
186 plan authorized under s. 409.91211. The agency may contract with
187 more than one comprehensive behavioral health provider to
188 provide care to recipients who are not enrolled in a Medicaid
189 capitated managed care plan authorized under s. 409.91211 or a
190 Medicaid health maintenance organization in AHCA areas where the
191 eligible population exceeds 150,000. In an AHCA area where the
192 Medicaid managed care pilot program is authorized pursuant to s.
193 409.91211 in one or more counties, the agency may procure a
194 contract with a single entity to serve the remaining counties as
195 an AHCA area or the remaining counties may be included with an
196 adjacent AHCA area and are shall be subject to this paragraph.
197 Contracts for comprehensive behavioral health providers awarded
198 pursuant to this section must shall be competitively procured.
199 Both for-profit and not-for-profit corporations are shall be
200 eligible to compete. Managed care plans contracting with the
201 agency under subsection (3) shall provide and receive payment
202 for the same comprehensive behavioral health benefits as
203 provided in AHCA rules, including handbooks incorporated by
204 reference. In AHCA area 11, the agency shall contract with at
205 least two comprehensive behavioral health care providers to
206 provide behavioral health care to recipients in that area who
207 are enrolled in, or assigned to, the MediPass program. One of
208 the behavioral health care contracts must shall be with the
209 existing provider service network pilot project, as described in
210 paragraph (d), for the purpose of demonstrating the cost
211 effectiveness of the provision of quality mental health services
212 through a public hospital-operated managed care model. Payment
213 shall be at an agreed-upon capitated rate to ensure cost
214 savings. Of the recipients in area 11 who are assigned to
215 MediPass under the provisions of s. 409.9122(2)(k), a minimum of
216 50,000 of those MediPass-enrolled recipients shall be assigned
217 to the existing provider service network in area 11 for their
218 behavioral care.
219 4. By October 1, 2003, the agency and the department shall
220 submit a plan to the Governor, the President of the Senate, and
221 the Speaker of the House of Representatives which provides for
222 the full implementation of capitated prepaid behavioral health
223 care in all areas of the state.
224 a. Implementation shall begin in 2003 in those AHCA areas
225 of the state where the agency is able to establish sufficient
226 capitation rates.
227 b. If the agency determines that the proposed capitation
228 rate in any area is insufficient to provide appropriate
229 services, the agency may adjust the capitation rate to ensure
230 that care is will be available. The agency and the department
231 may use existing general revenue to address any additional
232 required match but may not over-obligate existing funds on an
233 annualized basis.
234 c. Subject to any limitations provided for in the General
235 Appropriations Act, the agency, in compliance with appropriate
236 federal authorization, shall develop policies and procedures
237 that allow for certification of local and state funds.
238 5. Children residing in a statewide inpatient psychiatric
239 program, or in a Department of Juvenile Justice or a Department
240 of Children and Family Services residential program approved as
241 a Medicaid behavioral health overlay services provider may shall
242 not be included in a behavioral health care prepaid health plan
243 or any other Medicaid managed care plan pursuant to this
244 paragraph.
245 6. In converting to a prepaid system of delivery, the
246 agency shall in its procurement document require an entity
247 providing only comprehensive behavioral health care services to
248 prevent the displacement of indigent care patients by enrollees
249 in the Medicaid prepaid health plan providing behavioral health
250 care services from facilities receiving state funding to provide
251 indigent behavioral health care, to facilities licensed under
252 chapter 395 which do not receive state funding for indigent
253 behavioral health care, or reimburse the unsubsidized facility
254 for the cost of behavioral health care provided to the displaced
255 indigent care patient.
256 7. Traditional community mental health providers under
257 contract with the department of Children and Family Services
258 pursuant to part IV of chapter 394, child welfare providers
259 under contract with the department of Children and Family
260 Services in areas 1 and 6, and inpatient mental health providers
261 licensed pursuant to chapter 395 must be offered an opportunity
262 to accept or decline a contract to participate in any provider
263 network for prepaid behavioral health services.
264 8. All Medicaid-eligible children, except children in area
265 1 and children in Highlands County, Hardee County, Polk County,
266 or Manatee County of area 6, who are open for child welfare
267 services in the HomeSafeNet system, shall receive their
268 behavioral health care services through a specialty prepaid plan
269 operated by community-based lead agencies either through a
270 single agency or formal agreements among several agencies. The
271 specialty prepaid plan must result in savings to the state
272 comparable to savings achieved in other Medicaid managed care
273 and prepaid programs. Such plan must provide mechanisms to
274 maximize state and local revenues. The specialty prepaid plan
275 shall be developed by the agency and the department of Children
276 and Family Services. The agency may is authorized to seek any
277 federal waivers to implement this initiative. Medicaid-eligible
278 children whose cases are open for child welfare services in the
279 HomeSafeNet system and who reside in AHCA area 10 are exempt
280 from the specialty prepaid plan upon the development of a
281 service delivery mechanism for children who reside in area 10 as
282 specified in s. 409.91211(3)(dd).
283 9. To ensure unimpaired access to behavioral health care
284 services by Medicaid recipients, all contracts issued pursuant
285 to this paragraph must require that 80 percent of the capitation
286 paid to the managed care plan, including health maintenance
287 organizations, be expended for the provision of behavioral
288 health care services. If the plan expends less than 80 percent,
289 the difference must be returned to the agency and deposited into
290 the Medical Care Trust Fund. The agency shall maintain a
291 separate accounting of repayments deposited into the trust fund.
292 Repayments, minus federal matching funds that must be returned
293 to the Federal Government, shall be allocated to community
294 behavioral health providers enrolled in the networks of the
295 managed care plans that made the repayments. Funds shall be
296 allocated in proportion to each community behavioral health
297 agency’s earnings from the managed care plan making the
298 repayment. Providers shall use the funds for any Medicaid
299 allowable type of community behavioral health and case
300 management service. Community behavioral health agencies shall
301 be reimbursed by the agency on a fee-for-service basis for
302 allowable services up to their redistribution amount as
303 determined by the agency. Reinvestment amounts must be
304 calculated on an annual basis, within 60 days after managed care
305 plans file their annual 80 percent spending reports. The agency
306 shall provide the managed care plan with a certification letter
307 indicating the amount of capitation paid during each calendar
308 year for the provision of behavioral health care services
309 pursuant to this section.
310 Section 3. Paragraph (i) of subsection (2) of section
311 409.9122, Florida Statutes, is amended to read:
312 409.9122 Mandatory Medicaid managed care enrollment;
313 programs and procedures.—
314 (2)
315 (i) After a recipient has made his or her selection or has
316 been enrolled in a managed care plan or MediPass, the recipient
317 shall have 90 days to exercise the opportunity to voluntarily
318 disenroll and select another managed care plan or MediPass.
319 After 90 days, no further changes may be made except for good
320 cause. Good cause includes, but is not limited to, poor quality
321 of care, lack of access to necessary specialty services, an
322 unreasonable delay or denial of service, or fraudulent
323 enrollment, or severe and persistent mental illness. The agency
324 shall develop criteria for good cause disenrollment for
325 chronically ill and disabled populations who are assigned to
326 managed care plans if more appropriate care is available through
327 the MediPass program. The agency must make a determination as to
328 whether cause exists. However, the agency may require a
329 recipient to use the managed care plan’s or MediPass grievance
330 process prior to the agency’s determination of cause, except in
331 cases in which immediate risk of permanent damage to the
332 recipient’s health is alleged. The grievance process, when
333 utilized, must be completed in time to permit the recipient to
334 disenroll by the first day of the second month after the month
335 the disenrollment request was made. If the managed care plan or
336 MediPass, as a result of the grievance process, approves an
337 enrollee’s request to disenroll, the agency is not required to
338 make a determination in the case. The agency must make a
339 determination and take final action on a recipient’s request so
340 that disenrollment occurs no later than the first day of the
341 second month after the month the request was made. If the agency
342 fails to act within the specified timeframe, the recipient’s
343 request to disenroll is deemed to be approved as of the date
344 agency action was required. Recipients who disagree with the
345 agency’s finding that cause does not exist for disenrollment
346 shall be advised of their right to pursue a Medicaid fair
347 hearing to dispute the agency’s finding.
348 Section 4. This act shall take effect upon becoming a law.