HB 839

1
A bill to be entitled
2An act relating to Medicaid managed care plans; amending
3s. 409.912, F.S.; requiring that an entity contracting
4with the Agency for Health Care Administration to provide
5certain health care services continue to offer previously
6authorized services while prior authorization is
7processed, pay certain claims, and develop and maintain an
8informal grievance system; defining the term "clean
9claim"; requiring that the agency establish a formal
10grievance system; providing an effective date.
11
12Be It Enacted by the Legislature of the State of Florida:
13
14     Section 1.  Paragraph (b) of subsection (4) of section
15409.912, Florida Statutes, is amended to read:
16     409.912  Cost-effective purchasing of health care.--The
17agency shall purchase goods and services for Medicaid recipients
18in the most cost-effective manner consistent with the delivery
19of quality medical care. To ensure that medical services are
20effectively utilized, the agency may, in any case, require a
21confirmation or second physician's opinion of the correct
22diagnosis for purposes of authorizing future services under the
23Medicaid program. This section does not restrict access to
24emergency services or poststabilization care services as defined
25in 42 C.F.R. part 438.114. Such confirmation or second opinion
26shall be rendered in a manner approved by the agency. The agency
27shall maximize the use of prepaid per capita and prepaid
28aggregate fixed-sum basis services when appropriate and other
29alternative service delivery and reimbursement methodologies,
30including competitive bidding pursuant to s. 287.057, designed
31to facilitate the cost-effective purchase of a case-managed
32continuum of care. The agency shall also require providers to
33minimize the exposure of recipients to the need for acute
34inpatient, custodial, and other institutional care and the
35inappropriate or unnecessary use of high-cost services. The
36agency shall contract with a vendor to monitor and evaluate the
37clinical practice patterns of providers in order to identify
38trends that are outside the normal practice patterns of a
39provider's professional peers or the national guidelines of a
40provider's professional association. The vendor must be able to
41provide information and counseling to a provider whose practice
42patterns are outside the norms, in consultation with the agency,
43to improve patient care and reduce inappropriate utilization.
44The agency may mandate prior authorization, drug therapy
45management, or disease management participation for certain
46populations of Medicaid beneficiaries, certain drug classes, or
47particular drugs to prevent fraud, abuse, overuse, and possible
48dangerous drug interactions. The Pharmaceutical and Therapeutics
49Committee shall make recommendations to the agency on drugs for
50which prior authorization is required. The agency shall inform
51the Pharmaceutical and Therapeutics Committee of its decisions
52regarding drugs subject to prior authorization. The agency is
53authorized to limit the entities it contracts with or enrolls as
54Medicaid providers by developing a provider network through
55provider credentialing. The agency may competitively bid single-
56source-provider contracts if procurement of goods or services
57results in demonstrated cost savings to the state without
58limiting access to care. The agency may limit its network based
59on the assessment of beneficiary access to care, provider
60availability, provider quality standards, time and distance
61standards for access to care, the cultural competence of the
62provider network, demographic characteristics of Medicaid
63beneficiaries, practice and provider-to-beneficiary standards,
64appointment wait times, beneficiary use of services, provider
65turnover, provider profiling, provider licensure history,
66previous program integrity investigations and findings, peer
67review, provider Medicaid policy and billing compliance records,
68clinical and medical record audits, and other factors. Providers
69shall not be entitled to enrollment in the Medicaid provider
70network. The agency shall determine instances in which allowing
71Medicaid beneficiaries to purchase durable medical equipment and
72other goods is less expensive to the Medicaid program than long-
73term rental of the equipment or goods. The agency may establish
74rules to facilitate purchases in lieu of long-term rentals in
75order to protect against fraud and abuse in the Medicaid program
76as defined in s. 409.913. The agency may seek federal waivers
77necessary to administer these policies.
78     (4)  The agency may contract with:
79     (b)  An entity that is providing comprehensive behavioral
80health care services to certain Medicaid recipients through a
81capitated, prepaid arrangement pursuant to the federal waiver
82provided for by s. 409.905(5). Such an entity must be licensed
83under chapter 624, chapter 636, or chapter 641 and must possess
84the clinical systems and operational competence to manage risk
85and provide comprehensive behavioral health care to Medicaid
86recipients. As used in this paragraph, the term "comprehensive
87behavioral health care services" means covered mental health and
88substance abuse treatment services that are available to
89Medicaid recipients. The secretary of the Department of Children
90and Family Services shall approve provisions of procurements
91related to children in the department's care or custody prior to
92enrolling such children in a prepaid behavioral health plan. Any
93contract awarded under this paragraph must be competitively
94procured. In developing the behavioral health care prepaid plan
95procurement document, the agency shall ensure that the
96procurement document requires the contractor to develop and
97implement a plan to ensure compliance with s. 394.4574 related
98to services provided to residents of licensed assisted living
99facilities that hold a limited mental health license. Except as
100provided in subparagraph 8., and except in counties where the
101Medicaid managed care pilot program is authorized pursuant to s.
102409.91211, the agency shall seek federal approval to contract
103with a single entity meeting these requirements to provide
104comprehensive behavioral health care services to all Medicaid
105recipients not enrolled in a Medicaid managed care plan
106authorized under s. 409.91211 or a Medicaid health maintenance
107organization in an AHCA area. In an AHCA area where the Medicaid
108managed care pilot program is authorized pursuant to s.
109409.91211 in one or more counties, the agency may procure a
110contract with a single entity to serve the remaining counties as
111an AHCA area or the remaining counties may be included with an
112adjacent AHCA area and shall be subject to this paragraph. Each
113entity must offer sufficient choice of providers in its network
114to ensure recipient access to care and the opportunity to select
115a provider with whom they are satisfied. The network shall
116include all public mental health hospitals. To ensure unimpaired
117access to behavioral health care services by Medicaid
118recipients, all contracts issued pursuant to this paragraph
119shall require 80 percent of the capitation paid to the managed
120care plan, including health maintenance organizations, to be
121expended for the provision of behavioral health care services.
122In the event the managed care plan expends less than 80 percent
123of the capitation paid pursuant to this paragraph for the
124provision of behavioral health care services, the difference
125shall be returned to the agency. The agency shall provide the
126managed care plan with a certification letter indicating the
127amount of capitation paid during each calendar year for the
128provision of behavioral health care services pursuant to this
129section. The agency may reimburse for substance abuse treatment
130services on a fee-for-service basis until the agency finds that
131adequate funds are available for capitated, prepaid
132arrangements.
133     1.  By January 1, 2001, the agency shall modify the
134contracts with the entities providing comprehensive inpatient
135and outpatient mental health care services to Medicaid
136recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
137Counties, to include substance abuse treatment services.
138     2.  By July 1, 2003, the agency and the Department of
139Children and Family Services shall execute a written agreement
140that requires collaboration and joint development of all policy,
141budgets, procurement documents, contracts, and monitoring plans
142that have an impact on the state and Medicaid community mental
143health and targeted case management programs.
144     3.  Except as provided in subparagraph 8., by July 1, 2006,
145the agency and the Department of Children and Family Services
146shall contract with managed care entities in each AHCA area
147except area 6 or arrange to provide comprehensive inpatient and
148outpatient mental health and substance abuse services through
149capitated prepaid arrangements to all Medicaid recipients who
150are eligible to participate in such plans under federal law and
151regulation. In AHCA areas where eligible individuals number less
152than 150,000, the agency shall contract with a single managed
153care plan to provide comprehensive behavioral health services to
154all recipients who are not enrolled in a Medicaid health
155maintenance organization or a Medicaid capitated managed care
156plan authorized under s. 409.91211. The agency may contract with
157more than one comprehensive behavioral health provider to
158provide care to recipients who are not enrolled in a Medicaid
159capitated managed care plan authorized under s. 409.91211 or a
160Medicaid health maintenance organization in AHCA areas where the
161eligible population exceeds 150,000. In an AHCA area where the
162Medicaid managed care pilot program is authorized pursuant to s.
163409.91211 in one or more counties, the agency may procure a
164contract with a single entity to serve the remaining counties as
165an AHCA area or the remaining counties may be included with an
166adjacent AHCA area and shall be subject to this paragraph.
167Contracts for comprehensive behavioral health providers awarded
168pursuant to this section shall be competitively procured. Both
169for-profit and not-for-profit corporations shall be eligible to
170compete. Managed care plans contracting with the agency under
171subsection (3) shall provide and receive payment for the same
172comprehensive behavioral health benefits as provided in AHCA
173rules, including handbooks incorporated by reference. In AHCA
174area 11, the agency shall contract with at least two
175comprehensive behavioral health care providers to provide
176behavioral health care to recipients in that area who are
177enrolled in, or assigned to, the MediPass program. One of the
178behavioral health care contracts shall be with the existing
179provider service network pilot project, as described in
180paragraph (d), for the purpose of demonstrating the cost-
181effectiveness of the provision of quality mental health services
182through a public hospital-operated managed care model. Payment
183shall be at an agreed-upon capitated rate to ensure cost
184savings. Of the recipients in area 11 who are assigned to
185MediPass under the provisions of s. 409.9122(2)(k), a minimum of
18650,000 of those MediPass-enrolled recipients shall be assigned
187to the existing provider service network in area 11 for their
188behavioral care.
189     4.  By October 1, 2003, the agency and the department shall
190submit a plan to the Governor, the President of the Senate, and
191the Speaker of the House of Representatives which provides for
192the full implementation of capitated prepaid behavioral health
193care in all areas of the state.
194     a.  Implementation shall begin in 2003 in those AHCA areas
195of the state where the agency is able to establish sufficient
196capitation rates.
197     b.  If the agency determines that the proposed capitation
198rate in any area is insufficient to provide appropriate
199services, the agency may adjust the capitation rate to ensure
200that care will be available. The agency and the department may
201use existing general revenue to address any additional required
202match but may not over-obligate existing funds on an annualized
203basis.
204     c.  Subject to any limitations provided for in the General
205Appropriations Act, the agency, in compliance with appropriate
206federal authorization, shall develop policies and procedures
207that allow for certification of local and state funds.
208     5.  Children residing in a statewide inpatient psychiatric
209program, or in a Department of Juvenile Justice or a Department
210of Children and Family Services residential program approved as
211a Medicaid behavioral health overlay services provider shall not
212be included in a behavioral health care prepaid health plan or
213any other Medicaid managed care plan pursuant to this paragraph.
214     6.  In converting to a prepaid system of delivery, the
215agency shall in its procurement document require an entity
216providing only comprehensive behavioral health care services to
217prevent the displacement of indigent care patients by enrollees
218in the Medicaid prepaid health plan providing behavioral health
219care services from facilities receiving state funding to provide
220indigent behavioral health care, to facilities licensed under
221chapter 395 which do not receive state funding for indigent
222behavioral health care, or reimburse the unsubsidized facility
223for the cost of behavioral health care provided to the displaced
224indigent care patient.
225     7.  Traditional community mental health providers under
226contract with the Department of Children and Family Services
227pursuant to part IV of chapter 394, child welfare providers
228under contract with the Department of Children and Family
229Services in areas 1 and 6, and inpatient mental health providers
230licensed pursuant to chapter 395 must be offered an opportunity
231to accept or decline a contract to participate in any provider
232network for prepaid behavioral health services.
233     8.  All Medicaid-eligible children, except children in area
2341 and children in Highlands County, Hardee County, Polk County,
235or Manatee County of area 6, who are open for child welfare
236services in the HomeSafeNet system, shall receive their
237behavioral health care services through a specialty prepaid plan
238operated by community-based lead agencies either through a
239single agency or formal agreements among several agencies. The
240specialty prepaid plan must result in savings to the state
241comparable to savings achieved in other Medicaid managed care
242and prepaid programs. Such plan must provide mechanisms to
243maximize state and local revenues. The specialty prepaid plan
244shall be developed by the agency and the Department of Children
245and Family Services. The agency is authorized to seek any
246federal waivers to implement this initiative. Medicaid-eligible
247children whose cases are open for child welfare services in the
248HomeSafeNet system and who reside in AHCA area 10 are exempt
249from the specialty prepaid plan upon the development of a
250service delivery mechanism for children who reside in area 10 as
251specified in s. 409.91211(3)(dd).
252     9.  An entity providing comprehensive behavioral health
253care services and licensed under chapter 624, chapter 636, or
254chapter 641 shall:
255     a.  Continue services authorized by the previous entity as
256medically necessary while prior authorization is being processed
257under a new plan;
258     b.  Pay, within 10 business days after receipt, electronic
259clean claims containing sufficient information for processing.
260For purposes of this paragraph, the term "clean claim" means a
261claim that does not have any defect or impropriety, including
262the lack of any required substantiating documentation or
263particular circumstance requiring special treatment that
264prevents timely payment from being made; and
265     c.  Develop and maintain an informal grievance system that
266addresses payment and contract problems with physicians licensed
267under chapter 458 or chapter 459, psychologists licensed under
268chapter 490, psychotherapists as defined in chapter 491, or a
269facility operating under chapter 393, chapter 394, or chapter
270397. The agency shall also establish a formal grievance system
271to address those issues that are not resolved through the
272informal grievance system.
273     Section 2.  This act shall take effect July 1, 2009.


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