1 | A bill to be entitled |
2 | An act relating to Medicaid managed care plans; amending |
3 | s. 409.912, F.S.; requiring that an entity contracting |
4 | with the Agency for Health Care Administration to provide |
5 | certain health care services continue to offer previously |
6 | authorized services while prior authorization is |
7 | processed, pay certain claims, and develop and maintain an |
8 | informal grievance system; defining the term "clean |
9 | claim"; requiring that the agency establish a formal |
10 | grievance system; providing an effective date. |
11 |
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12 | Be It Enacted by the Legislature of the State of Florida: |
13 |
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14 | Section 1. Paragraph (b) of subsection (4) of section |
15 | 409.912, Florida Statutes, is amended to read: |
16 | 409.912 Cost-effective purchasing of health care.--The |
17 | agency shall purchase goods and services for Medicaid recipients |
18 | in the most cost-effective manner consistent with the delivery |
19 | of quality medical care. To ensure that medical services are |
20 | effectively utilized, the agency may, in any case, require a |
21 | confirmation or second physician's opinion of the correct |
22 | diagnosis for purposes of authorizing future services under the |
23 | Medicaid program. This section does not restrict access to |
24 | emergency services or poststabilization care services as defined |
25 | in 42 C.F.R. part 438.114. Such confirmation or second opinion |
26 | shall be rendered in a manner approved by the agency. The agency |
27 | shall maximize the use of prepaid per capita and prepaid |
28 | aggregate fixed-sum basis services when appropriate and other |
29 | alternative service delivery and reimbursement methodologies, |
30 | including competitive bidding pursuant to s. 287.057, designed |
31 | to facilitate the cost-effective purchase of a case-managed |
32 | continuum of care. The agency shall also require providers to |
33 | minimize the exposure of recipients to the need for acute |
34 | inpatient, custodial, and other institutional care and the |
35 | inappropriate or unnecessary use of high-cost services. The |
36 | agency shall contract with a vendor to monitor and evaluate the |
37 | clinical practice patterns of providers in order to identify |
38 | trends that are outside the normal practice patterns of a |
39 | provider's professional peers or the national guidelines of a |
40 | provider's professional association. The vendor must be able to |
41 | provide information and counseling to a provider whose practice |
42 | patterns are outside the norms, in consultation with the agency, |
43 | to improve patient care and reduce inappropriate utilization. |
44 | The agency may mandate prior authorization, drug therapy |
45 | management, or disease management participation for certain |
46 | populations of Medicaid beneficiaries, certain drug classes, or |
47 | particular drugs to prevent fraud, abuse, overuse, and possible |
48 | dangerous drug interactions. The Pharmaceutical and Therapeutics |
49 | Committee shall make recommendations to the agency on drugs for |
50 | which prior authorization is required. The agency shall inform |
51 | the Pharmaceutical and Therapeutics Committee of its decisions |
52 | regarding drugs subject to prior authorization. The agency is |
53 | authorized to limit the entities it contracts with or enrolls as |
54 | Medicaid providers by developing a provider network through |
55 | provider credentialing. The agency may competitively bid single- |
56 | source-provider contracts if procurement of goods or services |
57 | results in demonstrated cost savings to the state without |
58 | limiting access to care. The agency may limit its network based |
59 | on the assessment of beneficiary access to care, provider |
60 | availability, provider quality standards, time and distance |
61 | standards for access to care, the cultural competence of the |
62 | provider network, demographic characteristics of Medicaid |
63 | beneficiaries, practice and provider-to-beneficiary standards, |
64 | appointment wait times, beneficiary use of services, provider |
65 | turnover, provider profiling, provider licensure history, |
66 | previous program integrity investigations and findings, peer |
67 | review, provider Medicaid policy and billing compliance records, |
68 | clinical and medical record audits, and other factors. Providers |
69 | shall not be entitled to enrollment in the Medicaid provider |
70 | network. The agency shall determine instances in which allowing |
71 | Medicaid beneficiaries to purchase durable medical equipment and |
72 | other goods is less expensive to the Medicaid program than long- |
73 | term rental of the equipment or goods. The agency may establish |
74 | rules to facilitate purchases in lieu of long-term rentals in |
75 | order to protect against fraud and abuse in the Medicaid program |
76 | as defined in s. 409.913. The agency may seek federal waivers |
77 | necessary to administer these policies. |
78 | (4) The agency may contract with: |
79 | (b) An entity that is providing comprehensive behavioral |
80 | health care services to certain Medicaid recipients through a |
81 | capitated, prepaid arrangement pursuant to the federal waiver |
82 | provided for by s. 409.905(5). Such an entity must be licensed |
83 | under chapter 624, chapter 636, or chapter 641 and must possess |
84 | the clinical systems and operational competence to manage risk |
85 | and provide comprehensive behavioral health care to Medicaid |
86 | recipients. As used in this paragraph, the term "comprehensive |
87 | behavioral health care services" means covered mental health and |
88 | substance abuse treatment services that are available to |
89 | Medicaid recipients. The secretary of the Department of Children |
90 | and Family Services shall approve provisions of procurements |
91 | related to children in the department's care or custody prior to |
92 | enrolling such children in a prepaid behavioral health plan. Any |
93 | contract awarded under this paragraph must be competitively |
94 | procured. In developing the behavioral health care prepaid plan |
95 | procurement document, the agency shall ensure that the |
96 | procurement document requires the contractor to develop and |
97 | implement a plan to ensure compliance with s. 394.4574 related |
98 | to services provided to residents of licensed assisted living |
99 | facilities that hold a limited mental health license. Except as |
100 | provided in subparagraph 8., and except in counties where the |
101 | Medicaid managed care pilot program is authorized pursuant to s. |
102 | 409.91211, the agency shall seek federal approval to contract |
103 | with a single entity meeting these requirements to provide |
104 | comprehensive behavioral health care services to all Medicaid |
105 | recipients not enrolled in a Medicaid managed care plan |
106 | authorized under s. 409.91211 or a Medicaid health maintenance |
107 | organization in an AHCA area. In an AHCA area where the Medicaid |
108 | managed care pilot program is authorized pursuant to s. |
109 | 409.91211 in one or more counties, the agency may procure a |
110 | contract with a single entity to serve the remaining counties as |
111 | an AHCA area or the remaining counties may be included with an |
112 | adjacent AHCA area and shall be subject to this paragraph. Each |
113 | entity must offer sufficient choice of providers in its network |
114 | to ensure recipient access to care and the opportunity to select |
115 | a provider with whom they are satisfied. The network shall |
116 | include all public mental health hospitals. To ensure unimpaired |
117 | access to behavioral health care services by Medicaid |
118 | recipients, all contracts issued pursuant to this paragraph |
119 | shall require 80 percent of the capitation paid to the managed |
120 | care plan, including health maintenance organizations, to be |
121 | expended for the provision of behavioral health care services. |
122 | In the event the managed care plan expends less than 80 percent |
123 | of the capitation paid pursuant to this paragraph for the |
124 | provision of behavioral health care services, the difference |
125 | shall be returned to the agency. The agency shall provide the |
126 | managed care plan with a certification letter indicating the |
127 | amount of capitation paid during each calendar year for the |
128 | provision of behavioral health care services pursuant to this |
129 | section. The agency may reimburse for substance abuse treatment |
130 | services on a fee-for-service basis until the agency finds that |
131 | adequate funds are available for capitated, prepaid |
132 | arrangements. |
133 | 1. By January 1, 2001, the agency shall modify the |
134 | contracts with the entities providing comprehensive inpatient |
135 | and outpatient mental health care services to Medicaid |
136 | recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk |
137 | Counties, to include substance abuse treatment services. |
138 | 2. By July 1, 2003, the agency and the Department of |
139 | Children and Family Services shall execute a written agreement |
140 | that requires collaboration and joint development of all policy, |
141 | budgets, procurement documents, contracts, and monitoring plans |
142 | that have an impact on the state and Medicaid community mental |
143 | health and targeted case management programs. |
144 | 3. Except as provided in subparagraph 8., by July 1, 2006, |
145 | the agency and the Department of Children and Family Services |
146 | shall contract with managed care entities in each AHCA area |
147 | except area 6 or arrange to provide comprehensive inpatient and |
148 | outpatient mental health and substance abuse services through |
149 | capitated prepaid arrangements to all Medicaid recipients who |
150 | are eligible to participate in such plans under federal law and |
151 | regulation. In AHCA areas where eligible individuals number less |
152 | than 150,000, the agency shall contract with a single managed |
153 | care plan to provide comprehensive behavioral health services to |
154 | all recipients who are not enrolled in a Medicaid health |
155 | maintenance organization or a Medicaid capitated managed care |
156 | plan authorized under s. 409.91211. The agency may contract with |
157 | more than one comprehensive behavioral health provider to |
158 | provide care to recipients who are not enrolled in a Medicaid |
159 | capitated managed care plan authorized under s. 409.91211 or a |
160 | Medicaid health maintenance organization in AHCA areas where the |
161 | eligible population exceeds 150,000. In an AHCA area where the |
162 | Medicaid managed care pilot program is authorized pursuant to s. |
163 | 409.91211 in one or more counties, the agency may procure a |
164 | contract with a single entity to serve the remaining counties as |
165 | an AHCA area or the remaining counties may be included with an |
166 | adjacent AHCA area and shall be subject to this paragraph. |
167 | Contracts for comprehensive behavioral health providers awarded |
168 | pursuant to this section shall be competitively procured. Both |
169 | for-profit and not-for-profit corporations shall be eligible to |
170 | compete. Managed care plans contracting with the agency under |
171 | subsection (3) shall provide and receive payment for the same |
172 | comprehensive behavioral health benefits as provided in AHCA |
173 | rules, including handbooks incorporated by reference. In AHCA |
174 | area 11, the agency shall contract with at least two |
175 | comprehensive behavioral health care providers to provide |
176 | behavioral health care to recipients in that area who are |
177 | enrolled in, or assigned to, the MediPass program. One of the |
178 | behavioral health care contracts shall be with the existing |
179 | provider service network pilot project, as described in |
180 | paragraph (d), for the purpose of demonstrating the cost- |
181 | effectiveness of the provision of quality mental health services |
182 | through a public hospital-operated managed care model. Payment |
183 | shall be at an agreed-upon capitated rate to ensure cost |
184 | savings. Of the recipients in area 11 who are assigned to |
185 | MediPass under the provisions of s. 409.9122(2)(k), a minimum of |
186 | 50,000 of those MediPass-enrolled recipients shall be assigned |
187 | to the existing provider service network in area 11 for their |
188 | behavioral care. |
189 | 4. By October 1, 2003, the agency and the department shall |
190 | submit a plan to the Governor, the President of the Senate, and |
191 | the Speaker of the House of Representatives which provides for |
192 | the full implementation of capitated prepaid behavioral health |
193 | care in all areas of the state. |
194 | a. Implementation shall begin in 2003 in those AHCA areas |
195 | of the state where the agency is able to establish sufficient |
196 | capitation rates. |
197 | b. If the agency determines that the proposed capitation |
198 | rate in any area is insufficient to provide appropriate |
199 | services, the agency may adjust the capitation rate to ensure |
200 | that care will be available. The agency and the department may |
201 | use existing general revenue to address any additional required |
202 | match but may not over-obligate existing funds on an annualized |
203 | basis. |
204 | c. Subject to any limitations provided for in the General |
205 | Appropriations Act, the agency, in compliance with appropriate |
206 | federal authorization, shall develop policies and procedures |
207 | that allow for certification of local and state funds. |
208 | 5. Children residing in a statewide inpatient psychiatric |
209 | program, or in a Department of Juvenile Justice or a Department |
210 | of Children and Family Services residential program approved as |
211 | a Medicaid behavioral health overlay services provider shall not |
212 | be included in a behavioral health care prepaid health plan or |
213 | any other Medicaid managed care plan pursuant to this paragraph. |
214 | 6. In converting to a prepaid system of delivery, the |
215 | agency shall in its procurement document require an entity |
216 | providing only comprehensive behavioral health care services to |
217 | prevent the displacement of indigent care patients by enrollees |
218 | in the Medicaid prepaid health plan providing behavioral health |
219 | care services from facilities receiving state funding to provide |
220 | indigent behavioral health care, to facilities licensed under |
221 | chapter 395 which do not receive state funding for indigent |
222 | behavioral health care, or reimburse the unsubsidized facility |
223 | for the cost of behavioral health care provided to the displaced |
224 | indigent care patient. |
225 | 7. Traditional community mental health providers under |
226 | contract with the Department of Children and Family Services |
227 | pursuant to part IV of chapter 394, child welfare providers |
228 | under contract with the Department of Children and Family |
229 | Services in areas 1 and 6, and inpatient mental health providers |
230 | licensed pursuant to chapter 395 must be offered an opportunity |
231 | to accept or decline a contract to participate in any provider |
232 | network for prepaid behavioral health services. |
233 | 8. All Medicaid-eligible children, except children in area |
234 | 1 and children in Highlands County, Hardee County, Polk County, |
235 | or Manatee County of area 6, who are open for child welfare |
236 | services in the HomeSafeNet system, shall receive their |
237 | behavioral health care services through a specialty prepaid plan |
238 | operated by community-based lead agencies either through a |
239 | single agency or formal agreements among several agencies. The |
240 | specialty prepaid plan must result in savings to the state |
241 | comparable to savings achieved in other Medicaid managed care |
242 | and prepaid programs. Such plan must provide mechanisms to |
243 | maximize state and local revenues. The specialty prepaid plan |
244 | shall be developed by the agency and the Department of Children |
245 | and Family Services. The agency is authorized to seek any |
246 | federal waivers to implement this initiative. Medicaid-eligible |
247 | children whose cases are open for child welfare services in the |
248 | HomeSafeNet system and who reside in AHCA area 10 are exempt |
249 | from the specialty prepaid plan upon the development of a |
250 | service delivery mechanism for children who reside in area 10 as |
251 | specified in s. 409.91211(3)(dd). |
252 | 9. An entity providing comprehensive behavioral health |
253 | care services and licensed under chapter 624, chapter 636, or |
254 | chapter 641 shall: |
255 | a. Continue services authorized by the previous entity as |
256 | medically necessary while prior authorization is being processed |
257 | under a new plan; |
258 | b. Pay, within 10 business days after receipt, electronic |
259 | clean claims containing sufficient information for processing. |
260 | For purposes of this paragraph, the term "clean claim" means a |
261 | claim that does not have any defect or impropriety, including |
262 | the lack of any required substantiating documentation or |
263 | particular circumstance requiring special treatment that |
264 | prevents timely payment from being made; and |
265 | c. Develop and maintain an informal grievance system that |
266 | addresses payment and contract problems with physicians licensed |
267 | under chapter 458 or chapter 459, psychologists licensed under |
268 | chapter 490, psychotherapists as defined in chapter 491, or a |
269 | facility operating under chapter 393, chapter 394, or chapter |
270 | 397. The agency shall also establish a formal grievance system |
271 | to address those issues that are not resolved through the |
272 | informal grievance system. |
273 | Section 2. This act shall take effect July 1, 2009. |