Florida Senate - 2010 CS for SB 476
By the Committee on Children, Families, and Elder Affairs; and
Senators Altman, Sobel, and Detert
586-04387-10 2010476c1
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.912,
3 F.S.; requiring that funds repaid to the Agency for
4 Health Care Administration by managed care plans that
5 spend less than a certain percentage of the capitation
6 rate for behavioral health services be deposited into
7 the Medical Care Trust Fund; providing that such
8 repayments be allocated to community behavioral health
9 providers and used for Medicaid behavioral and case
10 management services; providing for payment to unpaid
11 providers; providing an effective date.
12
13 Be It Enacted by the Legislature of the State of Florida:
14
15 Section 1. Paragraph (b) of subsection (4) of section
16 409.912, Florida Statutes, is amended to read:
17 409.912 Cost-effective purchasing of health care.—The
18 agency shall purchase goods and services for Medicaid recipients
19 in the most cost-effective manner consistent with the delivery
20 of quality medical care. To ensure that medical services are
21 effectively utilized, the agency may, in any case, require a
22 confirmation or second physician’s opinion of the correct
23 diagnosis for purposes of authorizing future services under the
24 Medicaid program. This section does not restrict access to
25 emergency services or poststabilization care services as defined
26 in 42 C.F.R. part 438.114. Such confirmation or second opinion
27 shall be rendered in a manner approved by the agency. The agency
28 shall maximize the use of prepaid per capita and prepaid
29 aggregate fixed-sum basis services when appropriate and other
30 alternative service delivery and reimbursement methodologies,
31 including competitive bidding pursuant to s. 287.057, designed
32 to facilitate the cost-effective purchase of a case-managed
33 continuum of care. The agency shall also require providers to
34 minimize the exposure of recipients to the need for acute
35 inpatient, custodial, and other institutional care and the
36 inappropriate or unnecessary use of high-cost services. The
37 agency shall contract with a vendor to monitor and evaluate the
38 clinical practice patterns of providers in order to identify
39 trends that are outside the normal practice patterns of a
40 provider’s professional peers or the national guidelines of a
41 provider’s professional association. The vendor must be able to
42 provide information and counseling to a provider whose practice
43 patterns are outside the norms, in consultation with the agency,
44 to improve patient care and reduce inappropriate utilization.
45 The agency may mandate prior authorization, drug therapy
46 management, or disease management participation for certain
47 populations of Medicaid beneficiaries, certain drug classes, or
48 particular drugs to prevent fraud, abuse, overuse, and possible
49 dangerous drug interactions. The Pharmaceutical and Therapeutics
50 Committee shall make recommendations to the agency on drugs for
51 which prior authorization is required. The agency shall inform
52 the Pharmaceutical and Therapeutics Committee of its decisions
53 regarding drugs subject to prior authorization. The agency is
54 authorized to limit the entities it contracts with or enrolls as
55 Medicaid providers by developing a provider network through
56 provider credentialing. The agency may competitively bid single
57 source-provider contracts if procurement of goods or services
58 results in demonstrated cost savings to the state without
59 limiting access to care. The agency may limit its network based
60 on the assessment of beneficiary access to care, provider
61 availability, provider quality standards, time and distance
62 standards for access to care, the cultural competence of the
63 provider network, demographic characteristics of Medicaid
64 beneficiaries, practice and provider-to-beneficiary standards,
65 appointment wait times, beneficiary use of services, provider
66 turnover, provider profiling, provider licensure history,
67 previous program integrity investigations and findings, peer
68 review, provider Medicaid policy and billing compliance records,
69 clinical and medical record audits, and other factors. Providers
70 shall not be entitled to enrollment in the Medicaid provider
71 network. The agency shall determine instances in which allowing
72 Medicaid beneficiaries to purchase durable medical equipment and
73 other goods is less expensive to the Medicaid program than long
74 term rental of the equipment or goods. The agency may establish
75 rules to facilitate purchases in lieu of long-term rentals in
76 order to protect against fraud and abuse in the Medicaid program
77 as defined in s. 409.913. The agency may seek federal waivers
78 necessary to administer these policies.
79 (4) The agency may contract with:
80 (b) An entity that is providing comprehensive behavioral
81 health care services to certain Medicaid recipients through a
82 capitated, prepaid arrangement pursuant to the federal waiver
83 authorized in provided for by s. 409.905(5). Such entity must be
84 licensed under chapter 624, chapter 636, or chapter 641, or
85 authorized under paragraph (c), and must possess the clinical
86 systems and operational competence to manage risk and provide
87 comprehensive behavioral health care to Medicaid recipients. As
88 used in this paragraph, the term “comprehensive behavioral
89 health care services” means covered mental health and substance
90 abuse treatment services that are available to Medicaid
91 recipients. The Secretary of the Department of Children and
92 Family Services must shall approve provisions of procurements
93 related to children in the department’s care or custody before
94 enrolling such children in a prepaid behavioral health plan. Any
95 contract awarded under this paragraph must be competitively
96 procured. In developing the behavioral health care prepaid plan
97 procurement document, the agency shall ensure that the
98 procurement document requires the contractor to develop and
99 implement a plan that ensures to ensure compliance with s.
100 394.4574 related to services provided to residents of licensed
101 assisted living facilities that hold a limited mental health
102 license. Except as provided in subparagraph 8., and except in
103 counties where the Medicaid managed care pilot program is
104 authorized pursuant to s. 409.91211, the agency shall seek
105 federal approval to contract with a single entity meeting these
106 requirements to provide comprehensive behavioral health care
107 services to all Medicaid recipients not enrolled in a Medicaid
108 managed care plan authorized under s. 409.91211 or a Medicaid
109 health maintenance organization in an AHCA area. In an AHCA area
110 where the Medicaid managed care pilot program is authorized
111 pursuant to s. 409.91211 in one or more counties, the agency may
112 procure a contract with a single entity to serve the remaining
113 counties as an AHCA area or the remaining counties may be
114 included with an adjacent AHCA area and are subject to this
115 paragraph. Each entity must offer a sufficient choice of
116 providers in its network to ensure recipient access to care and
117 the opportunity to select a provider with whom they are
118 satisfied. The network must shall include all public mental
119 health hospitals. To ensure unimpaired access to behavioral
120 health care services by Medicaid recipients, all contracts
121 issued pursuant to this paragraph must require 80 percent of the
122 capitation paid to the managed care plan, including health
123 maintenance organizations, to be expended for the provision of
124 behavioral health care services. If the managed care plan
125 expends less than 80 percent of the capitation paid for the
126 provision of behavioral health care services, the difference
127 shall be returned to the agency. The agency shall provide the
128 plan with a certification letter indicating the amount of
129 capitation paid during each calendar year for behavioral health
130 care services pursuant to this section. The agency may reimburse
131 for substance abuse treatment services on a fee-for-service
132 basis until the agency finds that adequate funds are available
133 for capitated, prepaid arrangements.
134 1. By January 1, 2001, the agency shall modify the
135 contracts with the entities providing comprehensive inpatient
136 and outpatient mental health care services to Medicaid
137 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
138 Counties, to include substance abuse treatment services.
139 2. By July 1, 2003, the agency and the department of
140 Children and Family Services shall execute a written agreement
141 that requires collaboration and joint development of all policy,
142 budgets, procurement documents, contracts, and monitoring plans
143 that have an impact on the state and Medicaid community mental
144 health and targeted case management programs.
145 3. Except as provided in subparagraph 8., by July 1, 2006,
146 the agency and the department of Children and Family Services
147 shall contract with managed care entities in each AHCA area
148 except area 6 or arrange to provide comprehensive inpatient and
149 outpatient mental health and substance abuse services through
150 capitated prepaid arrangements to all Medicaid recipients who
151 are eligible to participate in such plans under federal law and
152 regulation. In AHCA areas where eligible individuals number
153 fewer less than 150,000, the agency shall contract with a single
154 managed care plan to provide comprehensive behavioral health
155 services to all recipients who are not enrolled in a Medicaid
156 health maintenance organization or a Medicaid capitated managed
157 care plan authorized under s. 409.91211. The agency may contract
158 with more than one comprehensive behavioral health provider to
159 provide care to recipients who are not enrolled in a Medicaid
160 capitated managed care plan authorized under s. 409.91211 or a
161 Medicaid health maintenance organization in AHCA areas where the
162 eligible population exceeds 150,000. In an AHCA area where the
163 Medicaid managed care pilot program is authorized pursuant to s.
164 409.91211 in one or more counties, the agency may procure a
165 contract with a single entity to serve the remaining counties as
166 an AHCA area or the remaining counties may be included with an
167 adjacent AHCA area and are shall be subject to this paragraph.
168 Contracts for comprehensive behavioral health providers awarded
169 pursuant to this section must shall be competitively procured.
170 Both for-profit and not-for-profit corporations are eligible to
171 compete. Managed care plans contracting with the agency under
172 subsection (3) must shall provide and receive payment for the
173 same comprehensive behavioral health benefits as provided in
174 AHCA rules, including handbooks incorporated by reference. In
175 AHCA area 11, the agency shall contract with at least two
176 comprehensive behavioral health care providers to provide
177 behavioral health care to recipients in that area who are
178 enrolled in, or assigned to, the MediPass program. One of the
179 behavioral health care contracts must be with the existing
180 provider service network pilot project, as described in
181 paragraph (d), for the purpose of demonstrating the cost
182 effectiveness of providing the provision of quality mental
183 health services through a public hospital-operated managed care
184 model. Payment shall be at an agreed-upon capitated rate to
185 ensure cost savings. Of the recipients in area 11 who are
186 assigned to MediPass under s. 409.9122(2)(k), a minimum of
187 50,000 of those MediPass-enrolled recipients shall be assigned
188 to the existing provider service network in area 11 for their
189 behavioral care.
190 4. By October 1, 2003, the agency and the department shall
191 submit a plan to the Governor, the President of the Senate, and
192 the Speaker of the House of Representatives which provides for
193 the full implementation of capitated prepaid behavioral health
194 care in all areas of the state.
195 a. Implementation shall begin in 2003 in those AHCA areas
196 of the state where the agency is able to establish sufficient
197 capitation rates.
198 b. If the agency determines that the proposed capitation
199 rate in any area is insufficient to provide appropriate
200 services, the agency may adjust the capitation rate to ensure
201 that care is will be available. The agency and the department
202 may use existing general revenue to address any additional
203 required match but may not over-obligate existing funds on an
204 annualized basis.
205 c. Subject to any limitations provided in the General
206 Appropriations Act, the agency, in compliance with appropriate
207 federal authorization, shall develop policies and procedures
208 that allow for certification of local and state funds.
209 5. Children residing in a statewide inpatient psychiatric
210 program, or in a Department of Juvenile Justice or a Department
211 of Children and Family Services residential program approved as
212 a Medicaid behavioral health overlay services provider may not
213 be included in a behavioral health care prepaid health plan or
214 any other Medicaid managed care plan pursuant to this paragraph.
215 6. In converting to a prepaid system of delivery, the
216 agency shall in its procurement document require an entity
217 providing only comprehensive behavioral health care services to
218 prevent the displacement of indigent care patients by enrollees
219 in the Medicaid prepaid health plan providing behavioral health
220 care services from facilities receiving state funding to provide
221 indigent behavioral health care, to facilities licensed under
222 chapter 395 which do not receive state funding for indigent
223 behavioral health care, or reimburse the unsubsidized facility
224 for the cost of behavioral health care provided to the displaced
225 indigent care patient.
226 7. Traditional community mental health providers under
227 contract with the department of Children and Family Services
228 pursuant to part IV of chapter 394, child welfare providers
229 under contract with the department of Children and Family
230 Services in areas 1 and 6, and inpatient mental health providers
231 licensed pursuant to chapter 395 must be offered an opportunity
232 to accept or decline a contract to participate in any provider
233 network for prepaid behavioral health services.
234 8. All Medicaid-eligible children, except children in area
235 1 and children in Highlands County, Hardee County, Polk County,
236 or Manatee County of area 6, that are open for child welfare
237 services in the HomeSafeNet system, shall receive their
238 behavioral health care services through a specialty prepaid plan
239 operated by community-based lead agencies through a single
240 agency or formal agreements among several agencies. The
241 specialty prepaid plan must result in savings to the state
242 comparable to savings achieved in other Medicaid managed care
243 and prepaid programs. Such plan must provide mechanisms to
244 maximize state and local revenues. The specialty prepaid plan
245 shall be developed by the agency and the department of Children
246 and Family Services. The agency may seek federal waivers to
247 implement this initiative. Medicaid-eligible children whose
248 cases are open for child welfare services in the HomeSafeNet
249 system and who reside in AHCA area 10 are exempt from the
250 specialty prepaid plan upon the development of a service
251 delivery mechanism for children who reside in area 10 as
252 specified in s. 409.91211(3)(dd).
253 9. To ensure unimpaired access to behavioral health care
254 services by Medicaid recipients, all contracts issued pursuant
255 to this paragraph must require that 80 percent of the capitation
256 paid to the managed care plan, including health maintenance
257 organizations, be expended for the provision of behavioral
258 health care services. If the plan expends less than 80 percent,
259 the difference must be returned to the agency and deposited into
260 the Medical Care Trust Fund. The agency shall maintain a
261 separate accounting of repayments deposited into the trust fund.
262 Repayments, minus federal matching funds that must be returned
263 to the Federal Government, shall be allocated to community
264 behavioral health providers enrolled in the networks of the
265 managed care plans that made the repayments. Funds shall be
266 allocated in proportion to each community behavioral health
267 agency’s earnings from the managed care plan making the
268 repayment. Providers shall use the funds for any Medicaid
269 allowable type of community behavioral health and case
270 management service. Community behavioral health agencies shall
271 be reimbursed by the agency on a fee-for-service basis for
272 allowable services up to their redistribution amount as
273 determined by the agency. Reinvestment amounts must be
274 calculated annually within 60 days after the managed care plan
275 files its annual 80 percent spending report. Community
276 behavioral health agencies enrolled in the provider network of a
277 managed care plan that failed to meet the 80 percent spending
278 requirement must submit encounter data information on all claims
279 not paid by the health plan for the fiscal year in which the 80
280 percent requirement was not met and appropriate documentation
281 demonstrating the medical necessity for the services provided.
282 The encounter data shall be the basis for the fee-for-service
283 reimbursement to the agencies.
284 Section 2. This act shall take effect July 1, 2010.