Bill Text: FL S0476 | 2010 | Regular Session | Comm Sub

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Bill Title: Medicaid/Behavioral Health Services [WPSC]

Spectrum: Slight Partisan Bill (Republican 2-1)

Status: (Failed) 2010-04-30 - Died in Committee on Health and Human Services Appropriations [S0476 Detail]

Download: Florida-2010-S0476-Comm_Sub.html

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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.