Bill Text: FL S0476 | 2010 | Regular Session | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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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-Introduced.html

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Florida Senate - 2010                                     SB 476 
 
By Senator Altman 
24-00499-10                                            2010476__ 
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 an effective date. 
11 
12  Be It Enacted by the Legislature of the State of Florida: 
13 
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  authorized in provided for by s. 409.905(5). Such entity must be 
83  licensed under chapter 624, chapter 636, or chapter 641, or 
84  authorized under paragraph (c), and must possess the clinical 
85  systems and operational competence to manage risk and provide 
86  comprehensive behavioral health care to Medicaid recipients. As 
87  used in this paragraph, the term “comprehensive behavioral 
88  health care services” means covered mental health and substance 
89  abuse treatment services that are available to Medicaid 
90  recipients. The Secretary of the Department of Children and 
91  Family Services must shall approve provisions of procurements 
92  related to children in the department’s care or custody before 
93  enrolling such children in a prepaid behavioral health plan. Any 
94  contract awarded under this paragraph must be competitively 
95  procured. In developing the behavioral health care prepaid plan 
96  procurement document, the agency shall ensure that the 
97  procurement document requires the contractor to develop and 
98  implement a plan that ensures to ensure compliance with s. 
99  394.4574 related to services provided to residents of licensed 
100  assisted living facilities that hold a limited mental health 
101  license. Except as provided in subparagraph 8., and except in 
102  counties where the Medicaid managed care pilot program is 
103  authorized pursuant to s. 409.91211, the agency shall seek 
104  federal approval to contract with a single entity meeting these 
105  requirements to provide comprehensive behavioral health care 
106  services to all Medicaid recipients not enrolled in a Medicaid 
107  managed care plan authorized under s. 409.91211 or a Medicaid 
108  health maintenance organization in an AHCA area. In an AHCA area 
109  where the Medicaid managed care pilot program is authorized 
110  pursuant to s. 409.91211 in one or more counties, the agency may 
111  procure a contract with a single entity to serve the remaining 
112  counties as an AHCA area or the remaining counties may be 
113  included with an adjacent AHCA area and are subject to this 
114  paragraph. Each entity must offer a sufficient choice of 
115  providers in its network to ensure recipient access to care and 
116  the opportunity to select a provider with whom they are 
117  satisfied. The network must shall include all public mental 
118  health hospitals. To ensure unimpaired access to behavioral 
119  health care services by Medicaid recipients, all contracts 
120  issued pursuant to this paragraph must require 80 percent of the 
121  capitation paid to the managed care plan, including health 
122  maintenance organizations, to be expended for the provision of 
123  behavioral health care services. If the managed care plan 
124  expends less than 80 percent of the capitation paid for the 
125  provision of behavioral health care services, the difference 
126  shall be returned to the agency. The agency shall provide the 
127  plan with a certification letter indicating the amount of 
128  capitation paid during each calendar year for behavioral health 
129  care services pursuant to this section. The agency may reimburse 
130  for substance abuse treatment services on a fee-for-service 
131  basis until the agency finds that adequate funds are available 
132  for capitated, prepaid 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 
152  fewer less than 150,000, the agency shall contract with a single 
153  managed care plan to provide comprehensive behavioral health 
154  services to all recipients who are not enrolled in a Medicaid 
155  health maintenance organization or a Medicaid capitated managed 
156  care plan authorized under s. 409.91211. The agency may contract 
157  with 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 are shall be subject to this paragraph. 
167  Contracts for comprehensive behavioral health providers awarded 
168  pursuant to this section must shall be competitively procured. 
169  Both for-profit and not-for-profit corporations are eligible to 
170  compete. Managed care plans contracting with the agency under 
171  subsection (3) must shall provide and receive payment for the 
172  same comprehensive behavioral health benefits as provided in 
173  AHCA rules, including handbooks incorporated by reference. In 
174  AHCA 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 must 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 providing the provision of quality mental 
182  health services through a public hospital-operated managed care 
183  model. Payment shall be at an agreed-upon capitated rate to 
184  ensure cost savings. Of the recipients in area 11 who are 
185  assigned to MediPass under 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 is will be available. The agency and the department 
201  may use existing general revenue to address any additional 
202  required match but may not over-obligate existing funds on an 
203  annualized basis. 
204         c. Subject to any limitations provided 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 may 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, that 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 through a single 
239  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 may seek federal waivers to 
246  implement this initiative. Medicaid-eligible children whose 
247  cases are open for child welfare services in the HomeSafeNet 
248  system and who reside in AHCA area 10 are exempt from the 
249  specialty prepaid plan upon the development of a service 
250  delivery mechanism for children who reside in area 10 as 
251  specified in s. 409.91211(3)(dd). 
252         9. To ensure unimpaired access to behavioral health care 
253  services by Medicaid recipients, all contracts issued pursuant 
254  to this paragraph must require that 80 percent of the capitation 
255  paid to the managed care plan, including health maintenance 
256  organizations, be expended for the provision of behavioral 
257  health care services. If the plan expends less than 80 percent, 
258  the difference must be returned to the agency and deposited into 
259  the Medical Care Trust Fund. The agency shall maintain a 
260  separate accounting of repayments deposited into the trust fund. 
261  Repayments, minus federal matching funds that must be returned 
262  to the Federal Government, shall be allocated to community 
263  behavioral health providers enrolled in the networks of the 
264  managed care plans that made the repayments. Funds shall be 
265  allocated in proportion to each community behavioral health 
266  agency’s earnings from the managed care plan making the 
267  repayment. Providers shall use the funds for any Medicaid 
268  allowable type of community behavioral health and case 
269  management service. Community behavioral health agencies shall 
270  be reimbursed by the agency on a fee-for-service basis for 
271  allowable services up to their redistribution amount as 
272  determined by the agency. Reinvestment amounts must be 
273  calculated annually within 60 days after the managed care plan 
274  files its annual 80 percent spending report. 
275         Section 2. This act shall take effect July 1, 2010.