Florida Senate - 2010 CS for SB 1484
By the Committee on Health and Human Services Appropriations;
and Senator Peaden
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.912,
3 F.S.; requiring the Agency for Health Care
4 Administration to impose a fine against a person under
5 contract with the agency who violates certain
6 provisions; requiring an entity that contracts with
7 the agency as a managed care plan to post a surety
8 bond with the agency or maintain an account of a
9 specified sum; requiring the agency to pursue the
10 entity if the entity terminates the contract with the
11 agency before the end date of the contract; amending
12 s. 409.91211, F.S.; extending by 3 years the statewide
13 implementation of an enhanced service delivery system
14 for the Florida Medicaid program; providing for the
15 expansion of the pilot project into counties that have
16 two or more plans and the capacity to serve the
17 designated population; requiring that the agency
18 provide certain specified data to the recipient when
19 selecting a capitated managed care plan; revising
20 certain requirements for entities performing choice
21 counseling for recipients; requiring the agency to
22 provide behavioral health care services to Medicaid
23 eligible children; extending a date by which the
24 behavioral health care services will be delivered to
25 children; authorizing the agency to extend the time to
26 continue operation of the pilot program; requiring
27 that the agency seek public input on extending and
28 expanding the managed care pilot program and post
29 certain information on its website; amending s.
30 409.912, F.S.; authorizing the Agency for Health Care
31 Administration to contract with an entity for the
32 provision of comprehensive behavioral health care
33 services to certain Medicaid recipients who are not
34 enrolled in a Medicaid managed care plan or a Medicaid
35 provider service network under certain circumstances;
36 providing an effective date.
38 Be It Enacted by the Legislature of the State of Florida:
40 Section 1. Present subsections (23) through (53) of section
41 409.912, Florida Statutes, are renumbered as subsections (24)
42 through (54), respectively, and a new subsection (23) is added
43 to that section, and present subsections (21) and (22) of that
44 section are amended, to read:
45 409.912 Cost-effective purchasing of health care.—The
46 agency shall purchase goods and services for Medicaid recipients
47 in the most cost-effective manner consistent with the delivery
48 of quality medical care. To ensure that medical services are
49 effectively utilized, the agency may, in any case, require a
50 confirmation or second physician’s opinion of the correct
51 diagnosis for purposes of authorizing future services under the
52 Medicaid program. This section does not restrict access to
53 emergency services or poststabilization care services as defined
54 in 42 C.F.R. part 438.114. Such confirmation or second opinion
55 shall be rendered in a manner approved by the agency. The agency
56 shall maximize the use of prepaid per capita and prepaid
57 aggregate fixed-sum basis services when appropriate and other
58 alternative service delivery and reimbursement methodologies,
59 including competitive bidding pursuant to s. 287.057, designed
60 to facilitate the cost-effective purchase of a case-managed
61 continuum of care. The agency shall also require providers to
62 minimize the exposure of recipients to the need for acute
63 inpatient, custodial, and other institutional care and the
64 inappropriate or unnecessary use of high-cost services. The
65 agency shall contract with a vendor to monitor and evaluate the
66 clinical practice patterns of providers in order to identify
67 trends that are outside the normal practice patterns of a
68 provider’s professional peers or the national guidelines of a
69 provider’s professional association. The vendor must be able to
70 provide information and counseling to a provider whose practice
71 patterns are outside the norms, in consultation with the agency,
72 to improve patient care and reduce inappropriate utilization.
73 The agency may mandate prior authorization, drug therapy
74 management, or disease management participation for certain
75 populations of Medicaid beneficiaries, certain drug classes, or
76 particular drugs to prevent fraud, abuse, overuse, and possible
77 dangerous drug interactions. The Pharmaceutical and Therapeutics
78 Committee shall make recommendations to the agency on drugs for
79 which prior authorization is required. The agency shall inform
80 the Pharmaceutical and Therapeutics Committee of its decisions
81 regarding drugs subject to prior authorization. The agency is
82 authorized to limit the entities it contracts with or enrolls as
83 Medicaid providers by developing a provider network through
84 provider credentialing. The agency may competitively bid single
85 source-provider contracts if procurement of goods or services
86 results in demonstrated cost savings to the state without
87 limiting access to care. The agency may limit its network based
88 on the assessment of beneficiary access to care, provider
89 availability, provider quality standards, time and distance
90 standards for access to care, the cultural competence of the
91 provider network, demographic characteristics of Medicaid
92 beneficiaries, practice and provider-to-beneficiary standards,
93 appointment wait times, beneficiary use of services, provider
94 turnover, provider profiling, provider licensure history,
95 previous program integrity investigations and findings, peer
96 review, provider Medicaid policy and billing compliance records,
97 clinical and medical record audits, and other factors. Providers
98 shall not be entitled to enrollment in the Medicaid provider
99 network. The agency shall determine instances in which allowing
100 Medicaid beneficiaries to purchase durable medical equipment and
101 other goods is less expensive to the Medicaid program than long
102 term rental of the equipment or goods. The agency may establish
103 rules to facilitate purchases in lieu of long-term rentals in
104 order to protect against fraud and abuse in the Medicaid program
105 as defined in s. 409.913. The agency may seek federal waivers
106 necessary to administer these policies.
107 (21) Any entity contracting with the agency pursuant to
108 this section to provide health care services to Medicaid
109 recipients is prohibited from engaging in any of the following
110 practices or activities:
111 (a) Practices that are discriminatory, including, but not
112 limited to, attempts to discourage participation on the basis of
113 actual or perceived health status.
114 (b) Activities that could mislead or confuse recipients, or
115 misrepresent the organization, its marketing representatives, or
116 the agency. Violations of this paragraph include, but are not
117 limited to:
118 1. False or misleading claims that marketing
119 representatives are employees or representatives of the state or
120 county, or of anyone other than the entity or the organization
121 by whom they are reimbursed.
122 2. False or misleading claims that the entity is
123 recommended or endorsed by any state or county agency, or by any
124 other organization which has not certified its endorsement in
125 writing to the entity.
126 3. False or misleading claims that the state or county
127 recommends that a Medicaid recipient enroll with an entity.
128 4. Claims that a Medicaid recipient will lose benefits
129 under the Medicaid program, or any other health or welfare
130 benefits to which the recipient is legally entitled, if the
131 recipient does not enroll with the entity.
132 (c) Granting or offering of any monetary or other valuable
133 consideration for enrollment, except as authorized by subsection
135 (d) Door-to-door solicitation of recipients who have not
136 contacted the entity or who have not invited the entity to make
137 a presentation.
138 (e) Solicitation of Medicaid recipients by marketing
139 representatives stationed in state offices unless approved and
140 supervised by the agency or its agent and approved by the
141 affected state agency when solicitation occurs in an office of
142 the state agency. The agency shall ensure that marketing
143 representatives stationed in state offices shall market their
144 managed care plans to Medicaid recipients only in designated
145 areas and in such a way as to not interfere with the recipients’
146 activities in the state office.
147 (f) Enrollment of Medicaid recipients.
148 (22) The agency shall may impose a fine for a violation of
149 this section or the contract with the agency by a person or
150 entity that is under contract with the agency. With respect to
151 any nonwillful violation, such fine shall not exceed $2,500 per
152 violation. In no event shall such fine exceed an aggregate
153 amount of $10,000 for all nonwillful violations arising out of
154 the same action. With respect to any knowing and willful
155 violation of this section or the contract with the agency, the
156 agency may impose a fine upon the entity in an amount not to
157 exceed $20,000 for each such violation. In no event shall such
158 fine exceed an aggregate amount of $100,000 for all knowing and
159 willful violations arising out of the same action.
160 (23) Any entity that contracts with the agency on a prepaid
161 or fixed-sum basis as a managed care plan as defined in s.
162 409.9122(2)(f) or s. 409.91211 shall post a surety bond with the
163 agency in an amount that is equivalent to a 1-year guaranteed
164 savings amount as specified in the contract. In lieu of a surety
165 bond, the agency may establish an irrevocable account in which
166 the vendor funds an equivalent amount over a 6-month period. The
167 purpose of the surety bond or account is to protect the agency
168 if the entity terminates its contract with the agency before the
169 scheduled end date for the contract. If the contract is
170 terminated by the vendor for any reason, the agency shall pursue
171 a claim against the surety bond or account for an early
172 termination fee. The early termination fee must be equal to
173 administrative costs incurred by the state due to the early
174 termination and the differential of the guaranteed savings based
175 on the original contract term and the corresponding termination
176 date. The agency shall terminate a vendor who does not reimburse
177 the state within 30 days after any early termination involving
178 administrative costs and requiring reimbursement of lost savings
179 from the Medicaid program.
180 Section 2. Subsections (1) through (6) of section
181 409.91211, Florida Statutes, are amended to read:
182 409.91211 Medicaid managed care pilot program.—
183 (1)(a) The agency is authorized to seek and implement
184 experimental, pilot, or demonstration project waivers, pursuant
185 to s. 1115 of the Social Security Act, to create a statewide
186 initiative to provide for a more efficient and effective service
187 delivery system that enhances quality of care and client
188 outcomes in the Florida Medicaid program pursuant to this
189 section. Phase one of the demonstration shall be implemented in
190 two geographic areas. One demonstration site shall include only
191 Broward County. A second demonstration site shall initially
192 include Duval County and shall be expanded to include Baker,
193 Clay, and Nassau Counties within 1 year after the Duval County
194 program becomes operational. The agency shall implement
195 expansion of the program to include the remaining counties of
196 the state and remaining eligibility groups in accordance with
197 the process specified in the federally approved special terms
198 and conditions numbered 11-W-00206/4, as approved by the federal
199 Centers for Medicare and Medicaid Services on October 19, 2005,
200 with a goal of full statewide implementation by June 30, 2014
202 (b) This waiver extension shall authority is contingent
203 upon federal approval to preserve the low-income pool upper
204 payment-limit funding mechanism for providers and hospitals,
205 including a guarantee of a reasonable growth factor, a
206 methodology to allow the use of a portion of these funds to
207 serve as a risk pool for demonstration sites, provisions to
208 preserve the state’s ability to use intergovernmental transfers,
209 and provisions to protect the disproportionate share program
210 authorized pursuant to this chapter. Upon completion of the
211 evaluation conducted under s. 3, ch. 2005-133, Laws of Florida,
212 The agency shall expand may request statewide expansion of the
213 demonstration to counties that have two or more plans and that
214 have capacity to serve the designated population projects. The
215 agency may expand to additional counties as plan capacity is
216 developed. Statewide phase-in to additional counties shall be
217 contingent upon review and approval by the Legislature. Under
218 the upper-payment-limit program, or the low-income pool as
219 implemented by the Agency for Health Care Administration
220 pursuant to federal waiver, the state matching funds required
221 for the program shall be provided by local governmental entities
222 through intergovernmental transfers in accordance with published
223 federal statutes and regulations. The Agency for Health Care
224 Administration shall distribute upper-payment-limit,
225 disproportionate share hospital , and low-income pool funds
226 according to published federal statutes, regulations, and
227 waivers and the low-income pool methodology approved by the
228 federal Centers for Medicare and Medicaid Services.
229 (c) It is the intent of the Legislature that the low-income
230 pool plan required by the terms and conditions of the Medicaid
231 reform waiver and submitted to the federal Centers for Medicare
232 and Medicaid Services propose the distribution of the above
233 mentioned program funds based on the following objectives:
234 1. Assure a broad and fair distribution of available funds
235 based on the access provided by Medicaid participating
236 hospitals, regardless of their ownership status, through their
237 delivery of inpatient or outpatient care for Medicaid
238 beneficiaries and uninsured and underinsured individuals;
239 2. Assure accessible emergency inpatient and outpatient
240 care for Medicaid beneficiaries and uninsured and underinsured
242 3. Enhance primary, preventive, and other ambulatory care
243 coverages for uninsured individuals;
244 4. Promote teaching and specialty hospital programs;
245 5. Promote the stability and viability of statutorily
246 defined rural hospitals and hospitals that serve as sole
247 community hospitals;
248 6. Recognize the extent of hospital uncompensated care
250 7. Maintain and enhance essential community hospital care;
251 8. Maintain incentives for local governmental entities to
252 contribute to the cost of uncompensated care;
253 9. Promote measures to avoid preventable hospitalizations;
254 10. Account for hospital efficiency; and
255 11. Contribute to a community’s overall health system.
256 (2) The Legislature intends for the capitated managed care
257 pilot program to:
258 (a) Provide recipients in Medicaid fee-for-service or the
259 MediPass program a comprehensive and coordinated capitated
260 managed care system for all health care services specified in
261 ss. 409.905 and 409.906.
262 (b) Stabilize Medicaid expenditures under the pilot program
263 compared to Medicaid expenditures in the pilot area for the 3
264 years before implementation of the pilot program, while
266 1. Consumer education and choice.
267 2. Access to medically necessary services.
268 3. Coordination of preventative, acute, and long-term care.
269 4. Reductions in unnecessary service utilization.
270 (c) Provide an opportunity to evaluate the feasibility of
271 statewide implementation of capitated managed care networks as a
272 replacement for the current Medicaid fee-for-service and
273 MediPass systems.
274 (3) The agency shall have the following powers, duties, and
275 responsibilities with respect to the pilot program:
276 (a) To implement a system to deliver all mandatory services
277 specified in s. 409.905 and optional services specified in s.
278 409.906, as approved by the Centers for Medicare and Medicaid
279 Services and the Legislature in the waiver pursuant to this
280 section. Services to recipients under plan benefits shall
281 include emergency services provided under s. 409.9128.
282 (b) To implement a pilot program, including Medicaid
283 eligibility categories specified in ss. 409.903 and 409.904, as
284 authorized in an approved federal waiver.
285 (c) To implement the managed care pilot program that
286 maximizes all available state and federal funds, including those
287 obtained through intergovernmental transfers, the low-income
288 pool, supplemental Medicaid payments, and the disproportionate
289 share program. Within the parameters allowed by federal statute
290 and rule, the agency may seek options for making direct payments
291 to hospitals and physicians employed by or under contract with
292 the state’s medical schools for the costs associated with
293 graduate medical education under Medicaid reform.
294 (d) To implement actuarially sound, risk-adjusted
295 capitation rates for Medicaid recipients in the pilot program
296 which cover comprehensive care, enhanced services, and
297 catastrophic care.
298 (e) To implement policies and guidelines for phasing in
299 financial risk for approved provider service networks that, for
300 purposes of this paragraph, include the Children’s Medical
301 Services Network, over a 5-year period. These policies and
302 guidelines must include an option for a provider service network
303 to be paid fee-for-service rates. For any provider service
304 network established in a managed care pilot area, the option to
305 be paid fee-for-service rates must include a savings-settlement
306 mechanism that is consistent with s. 409.912(44). This model
307 must be converted to a risk-adjusted capitated rate by the
308 beginning of the sixth year of operation, and may be converted
309 earlier at the option of the provider service network. Federally
310 qualified health centers may be offered an opportunity to accept
311 or decline a contract to participate in any provider network for
312 prepaid primary care services.
313 (f) To implement stop-loss requirements and the transfer of
314 excess cost to catastrophic coverage that accommodates the risks
315 associated with the development of the pilot program.
316 (g) To recommend a process to be used by the Social
317 Services Estimating Conference to determine and validate the
318 rate of growth of the per-member costs of providing Medicaid
319 services under the managed care pilot program.
320 (h) To implement program standards and credentialing
321 requirements for capitated managed care networks to participate
322 in the pilot program, including those related to fiscal
323 solvency, quality of care, and adequacy of access to health care
324 providers. It is the intent of the Legislature that, to the
325 extent possible, any pilot program authorized by the state under
326 this section include any federally qualified health center,
327 federally qualified rural health clinic, county health
328 department, the Children’s Medical Services Network within the
329 Department of Health, or other federally, state, or locally
330 funded entity that serves the geographic areas within the
331 boundaries of the pilot program that requests to participate.
332 This paragraph does not relieve an entity that qualifies as a
333 capitated managed care network under this section from any other
334 licensure or regulatory requirements contained in state or
335 federal law which would otherwise apply to the entity. The
336 standards and credentialing requirements shall be based upon,
337 but are not limited to:
338 1. Compliance with the accreditation requirements as
339 provided in s. 641.512.
340 2. Compliance with early and periodic screening, diagnosis,
341 and treatment screening requirements under federal law.
342 3. The percentage of voluntary disenrollments.
343 4. Immunization rates.
344 5. Standards of the National Committee for Quality
345 Assurance and other approved accrediting bodies.
346 6. Recommendations of other authoritative bodies.
347 7. Specific requirements of the Medicaid program, or
348 standards designed to specifically meet the unique needs of
349 Medicaid recipients.
350 8. Compliance with the health quality improvement system as
351 established by the agency, which incorporates standards and
352 guidelines developed by the Centers for Medicare and Medicaid
353 Services as part of the quality assurance reform initiative.
354 9. The network’s infrastructure capacity to manage
355 financial transactions, recordkeeping, data collection, and
356 other administrative functions.
357 10. The network’s ability to submit any financial,
358 programmatic, or patient-encounter data or other information
359 required by the agency to determine the actual services provided
360 and the cost of administering the plan.
361 (i) To implement a mechanism for providing information to
362 Medicaid recipients for the purpose of selecting a capitated
363 managed care plan. For each plan available to a recipient, the
364 agency, at a minimum, shall ensure that the recipient is
365 provided with:
366 1. A list and description of the benefits provided.
367 2. Information about cost sharing.
368 3. A list of providers participating in the plan networks.
369 4. 3. Plan performance data, if available.
370 4. An explanation of benefit limitations.
371 5. Contact information, including identification of
372 providers participating in the network, geographic locations,
373 and transportation limitations.
374 6. Any other information the agency determines would
375 facilitate a recipient’s understanding of the plan or insurance
376 that would best meet his or her needs.
377 (j) To implement a system to ensure that there is a record
378 of recipient acknowledgment that plan choice counseling has been
380 (k) To implement a choice counseling system to ensure that
381 the choice counseling process and related material are designed
382 to provide counseling through face-to-face interaction, by
383 telephone or , and in writing and through other forms of relevant
384 media. Materials shall be written at the fourth-grade reading
385 level and available in a language other than English when 5
386 percent of the county speaks a language other than English.
387 Choice counseling shall also use language lines and other
388 services for impaired recipients, such as TTD/TTY.
389 (l) To implement a system that prohibits capitated managed
390 care plans, their representatives, and providers employed by or
391 contracted with the capitated managed care plans from recruiting
392 persons eligible for or enrolled in Medicaid, from providing
393 inducements to Medicaid recipients to select a particular
394 capitated managed care plan, and from prejudicing Medicaid
395 recipients against other capitated managed care plans. The
396 system shall require the entity performing choice counseling to
397 determine if the recipient has made a choice of a plan or has
398 opted out because of duress, threats, payment to the recipient,
399 or incentives promised to the recipient by a third party. If the
400 choice counseling entity determines that the decision to choose
401 a plan was unlawfully influenced or a plan violated any of the
402 provisions of s. 409.912(21), the choice counseling entity shall
403 immediately report the violation to the agency’s program
404 integrity section for investigation. Verification of choice
405 counseling by the recipient shall include a stipulation that the
406 recipient acknowledges the provisions of this subsection.
407 (m) To implement a choice counseling system that promotes
408 health literacy, uses technology effectively, and provides
409 information intended aimed to reduce minority health disparities
410 through outreach activities for Medicaid recipients.
411 (n) To contract with entities to perform choice counseling.
412 The agency may establish standards and performance contracts,
413 including standards requiring the contractor to hire choice
414 counselors who are representative of the state’s diverse
415 population and to train choice counselors in working with
416 culturally diverse populations.
417 (o) To implement eligibility assignment processes to
418 facilitate client choice while ensuring pilot programs of
419 adequate enrollment levels. These processes shall ensure that
420 pilot sites have sufficient levels of enrollment to conduct a
421 valid test of the managed care pilot program within a 2-year
423 (p) To implement standards for plan compliance, including,
424 but not limited to, standards for quality assurance and
425 performance improvement, standards for peer or professional
426 reviews, grievance policies, and policies for maintaining
427 program integrity. The agency shall develop a data-reporting
428 system, seek input from managed care plans in order to establish
429 requirements for patient-encounter reporting, and ensure that
430 the data reported is accurate and complete.
431 1. In performing the duties required under this section,
432 the agency shall work with managed care plans to establish a
433 uniform system to measure and monitor outcomes for a recipient
434 of Medicaid services.
435 2. The system shall use financial, clinical, and other
436 criteria based on pharmacy, medical services, and other data
437 that is related to the provision of Medicaid services,
438 including, but not limited to:
439 a. The Health Plan Employer Data and Information Set
440 (HEDIS) or measures that are similar to HEDIS.
441 b. Member satisfaction.
442 c. Provider satisfaction.
443 d. Report cards on plan performance and best practices.
444 e. Compliance with the requirements for prompt payment of
445 claims under ss. 627.613, 641.3155, and 641.513.
446 f. Utilization and quality data for the purpose of ensuring
447 access to medically necessary services, including
448 underutilization or inappropriate denial of services.
449 3. The agency shall require the managed care plans that
450 have contracted with the agency to establish a quality assurance
451 system that incorporates the provisions of s. 409.912(27) and
452 any standards, rules, and guidelines developed by the agency.
453 4. The agency shall establish an encounter database in
454 order to compile data on health services rendered by health care
455 practitioners who provide services to patients enrolled in
456 managed care plans in the demonstration sites. The encounter
457 database shall:
458 a. Collect the following for each type of patient encounter
459 with a health care practitioner or facility, including:
460 (I) The demographic characteristics of the patient.
461 (II) The principal, secondary, and tertiary diagnosis.
462 (III) The procedure performed.
463 (IV) The date and location where the procedure was
465 (V) The payment for the procedure, if any.
466 (VI) If applicable, the health care practitioner’s
467 universal identification number.
468 (VII) If the health care practitioner rendering the service
469 is a dependent practitioner, the modifiers appropriate to
470 indicate that the service was delivered by the dependent
472 b. Collect appropriate information relating to prescription
473 drugs for each type of patient encounter.
474 c. Collect appropriate information related to health care
475 costs and utilization from managed care plans participating in
476 the demonstration sites.
477 5. To the extent practicable, when collecting the data the
478 agency shall use a standardized claim form or electronic
479 transfer system that is used by health care practitioners,
480 facilities, and payors.
481 6. Health care practitioners and facilities in the
482 demonstration sites shall electronically submit, and managed
483 care plans participating in the demonstration sites shall
484 electronically receive, information concerning claims payments
485 and any other information reasonably related to the encounter
486 database using a standard format as required by the agency.
487 7. The agency shall establish reasonable deadlines for
488 phasing in the electronic transmittal of full encounter data.
489 8. The system must ensure that the data reported is
490 accurate and complete.
491 (q) To implement a grievance resolution process for
492 Medicaid recipients enrolled in a capitated managed care network
493 under the pilot program modeled after the subscriber assistance
494 panel, as created in s. 408.7056. This process shall include a
495 mechanism for an expedited review of no greater than 24 hours
496 after notification of a grievance if the life of a Medicaid
497 recipient is in imminent and emergent jeopardy.
498 (r) To implement a grievance resolution process for health
499 care providers employed by or contracted with a capitated
500 managed care network under the pilot program in order to settle
501 disputes among the provider and the managed care network or the
502 provider and the agency.
503 (s) To implement criteria in an approved federal waiver to
504 designate health care providers as eligible to participate in
505 the pilot program. These criteria must include at a minimum
506 those criteria specified in s. 409.907.
507 (t) To use health care provider agreements for
508 participation in the pilot program.
509 (u) To require that all health care providers under
510 contract with the pilot program be duly licensed in the state,
511 if such licensure is available, and meet other criteria as may
512 be established by the agency. These criteria shall include at a
513 minimum those criteria specified in s. 409.907.
514 (v) To ensure that managed care organizations work
515 collaboratively with other state or local governmental programs
516 or institutions for the coordination of health care to eligible
517 individuals receiving services from such programs or
519 (w) To implement procedures to minimize the risk of
520 Medicaid fraud and abuse in all plans operating in the Medicaid
521 managed care pilot program authorized in this section.
522 1. The agency shall ensure that applicable provisions of
523 this chapter and chapters 414, 626, 641, and 932 which relate to
524 Medicaid fraud and abuse are applied and enforced at the
525 demonstration project sites.
526 2. Providers must have the certification, license, and
527 credentials that are required by law and waiver requirements.
528 3. The agency shall ensure that the plan is in compliance
529 with s. 409.912(21) and (22).
530 4. The agency shall require that each plan establish
531 functions and activities governing program integrity in order to
532 reduce the incidence of fraud and abuse. Plans must report
533 instances of fraud and abuse pursuant to chapter 641.
534 5. The plan shall have written administrative and
535 management arrangements or procedures, including a mandatory
536 compliance plan, which are designed to guard against fraud and
537 abuse. The plan shall designate a compliance officer who has
538 sufficient experience in health care.
539 6.a. The agency shall require all managed care plan
540 contractors in the pilot program to report all instances of
541 suspected fraud and abuse. A failure to report instances of
542 suspected fraud and abuse is a violation of law and subject to
543 the penalties provided by law.
544 b. An instance of fraud and abuse in the managed care plan,
545 including, but not limited to, defrauding the state health care
546 benefit program by misrepresentation of fact in reports, claims,
547 certifications, enrollment claims, demographic statistics, or
548 patient-encounter data; misrepresentation of the qualifications
549 of persons rendering health care and ancillary services; bribery
550 and false statements relating to the delivery of health care;
551 unfair and deceptive marketing practices; and false claims
552 actions in the provision of managed care, is a violation of law
553 and subject to the penalties provided by law.
554 c. The agency shall require that all contractors make all
555 files and relevant billing and claims data accessible to state
556 regulators and investigators and that all such data is linked
557 into a unified system to ensure consistent reviews and
559 (x) To develop and provide actuarial and benefit design
560 analyses that indicate the effect on capitation rates and
561 benefits offered in the pilot program over a prospective 5-year
562 period based on the following assumptions:
563 1. Growth in capitation rates which is limited to the
564 estimated growth rate in general revenue.
565 2. Growth in capitation rates which is limited to the
566 average growth rate over the last 3 years in per-recipient
567 Medicaid expenditures.
568 3. Growth in capitation rates which is limited to the
569 growth rate of aggregate Medicaid expenditures between the 2003
570 2004 fiscal year and the 2004-2005 fiscal year.
571 (y) To develop a mechanism to require capitated managed
572 care plans to reimburse qualified emergency service providers,
573 including, but not limited to, ambulance services, in accordance
574 with ss. 409.908 and 409.9128. The pilot program must include a
575 provision for continuing fee-for-service payments for emergency
576 services, including, but not limited to, individuals who access
577 ambulance services or emergency departments and who are
578 subsequently determined to be eligible for Medicaid services.
579 (z) To ensure that school districts participating in the
580 certified school match program pursuant to ss. 409.908(21) and
581 1011.70 shall be reimbursed by Medicaid, subject to the
582 limitations of s. 1011.70(1), for a Medicaid-eligible child
583 participating in the services as authorized in s. 1011.70, as
584 provided for in s. 409.9071, regardless of whether the child is
585 enrolled in a capitated managed care network. Capitated managed
586 care networks must make a good faith effort to execute
587 agreements with school districts regarding the coordinated
588 provision of services authorized under s. 1011.70. County health
589 departments and federally qualified health centers delivering
590 school-based services pursuant to ss. 381.0056 and 381.0057 must
591 be reimbursed by Medicaid for the federal share for a Medicaid
592 eligible child who receives Medicaid-covered services in a
593 school setting, regardless of whether the child is enrolled in a
594 capitated managed care network. Capitated managed care networks
595 must make a good faith effort to execute agreements with county
596 health departments and federally qualified health centers
597 regarding the coordinated provision of services to a Medicaid
598 eligible child. To ensure continuity of care for Medicaid
599 patients, the agency, the Department of Health, and the
600 Department of Education shall develop procedures for ensuring
601 that a student’s capitated managed care network provider
602 receives information relating to services provided in accordance
603 with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
604 (aa) To implement a mechanism whereby Medicaid recipients
605 who are already enrolled in a managed care plan or the MediPass
606 program in the pilot areas shall be offered the opportunity to
607 change to capitated managed care plans on a staggered basis, as
608 defined by the agency. All Medicaid recipients shall have 30
609 days in which to make a choice of capitated managed care plans.
610 Those Medicaid recipients who do not make a choice shall be
611 assigned to a capitated managed care plan in accordance with
612 paragraph (4)(a) and shall be exempt from s. 409.9122. To
613 facilitate continuity of care for a Medicaid recipient who is
614 also a recipient of Supplemental Security Income (SSI), prior to
615 assigning the SSI recipient to a capitated managed care plan,
616 the agency shall determine whether the SSI recipient has an
617 ongoing relationship with a provider or capitated managed care
618 plan, and, if so, the agency shall assign the SSI recipient to
619 that provider or capitated managed care plan where feasible.
620 Those SSI recipients who do not have such a provider
621 relationship shall be assigned to a capitated managed care plan
622 provider in accordance with paragraph (4)(a) and shall be exempt
623 from s. 409.9122.
624 (bb) To develop and recommend a service delivery
625 alternative for children having chronic medical conditions which
626 establishes a medical home project to provide primary care
627 services to this population. The project shall provide
628 community-based primary care services that are integrated with
629 other subspecialties to meet the medical, developmental, and
630 emotional needs for children and their families. This project
631 shall include an evaluation component to determine impacts on
632 hospitalizations, length of stays, emergency room visits, costs,
633 and access to care, including specialty care and patient and
634 family satisfaction.
635 (cc) To develop and recommend service delivery mechanisms
636 within capitated managed care plans to provide Medicaid services
637 as specified in ss. 409.905 and 409.906 to persons with
638 developmental disabilities sufficient to meet the medical,
639 developmental, and emotional needs of these persons.
640 (dd) To implement service delivery mechanisms within a
641 specialty plan capitated managed care plans to provide
642 behavioral health care services Medicaid services as specified
643 in ss. 409.905 and 409.906 to Medicaid-eligible children whose
644 cases are open for child welfare services in the HomeSafeNet
645 system. These services must be coordinated with community-based
646 care providers as specified in s. 409.1671, where available, and
647 be sufficient to meet the medical, developmental, behavioral,
648 and emotional needs of these children. Children in area 10 who
649 have an open case in the HomeSafeNet system shall be enrolled
650 into the specialty plan. These service delivery mechanisms must
651 be implemented no later than July 1, 2011 2008, in AHCA area 10
652 in order for the children in AHCA area 10 to remain exempt from
653 the statewide plan under s. 409.912(4)(b)8. An administrative
654 fee may be paid to the specialty plan for the coordination of
655 services based on the receipt of the state share of that fee
656 being provided through intergovernmental transfers.
657 (4)(a) A Medicaid recipient in the pilot area who is not
658 currently enrolled in a capitated managed care plan upon
659 implementation is not eligible for services as specified in ss.
660 409.905 and 409.906, for the amount of time that the recipient
661 does not enroll in a capitated managed care network. If a
662 Medicaid recipient has not enrolled in a capitated managed care
663 plan within 30 days after eligibility, the agency shall assign
664 the Medicaid recipient to a capitated managed care plan based on
665 the assessed needs of the recipient as determined by the agency
666 and the recipient shall be exempt from s. 409.9122. When making
667 assignments, the agency shall take into account the following
669 1. A capitated managed care network has sufficient network
670 capacity to meet the needs of members.
671 2. The capitated managed care network has previously
672 enrolled the recipient as a member, or one of the capitated
673 managed care network’s primary care providers has previously
674 provided health care to the recipient.
675 3. The agency has knowledge that the member has previously
676 expressed a preference for a particular capitated managed care
677 network as indicated by Medicaid fee-for-service claims data,
678 but has failed to make a choice.
679 4. The capitated managed care network’s primary care
680 providers are geographically accessible to the recipient’s
682 5. Plan performance as designed by the agency.
683 (b) When more than one capitated managed care network
684 provider meets the criteria specified in paragraph (3)(h), the
685 agency shall make recipient assignments consecutively by family
687 (c) If a recipient is currently enrolled with a Medicaid
688 managed care organization that also operates an approved reform
689 plan within a demonstration area and the recipient fails to
690 choose a plan during the reform enrollment process or during
691 redetermination of eligibility, the recipient shall be
692 automatically assigned by the agency into the most appropriate
693 reform plan operated by the recipient’s current Medicaid managed
694 care plan. If the recipient’s current managed care plan does not
695 operate a reform plan in the demonstration area which adequately
696 meets the needs of the Medicaid recipient, the agency shall use
697 the automatic assignment process as prescribed in the special
698 terms and conditions numbered 11-W-00206/4. All enrollment and
699 choice counseling materials provided by the agency must contain
700 an explanation of the provisions of this paragraph for current
701 managed care recipients.
702 (d) Except for plan performance as provided for in
703 paragraph (a), the agency may not engage in practices that are
704 designed to favor one capitated managed care plan over another
705 or that are designed to influence Medicaid recipients to enroll
706 in a particular capitated managed care network in order to
707 strengthen its particular fiscal viability.
708 (e) After a recipient has made a selection or has been
709 enrolled in a capitated managed care network, the recipient
710 shall have 90 days in which to voluntarily disenroll and select
711 another capitated managed care network. After 90 days, no
712 further changes may be made except for cause. Cause shall
713 include, but not be limited to, poor quality of care, lack of
714 access to necessary specialty services, an unreasonable delay or
715 denial of service, inordinate or inappropriate changes of
716 primary care providers, service access impairments due to
717 significant changes in the geographic location of services, or
718 fraudulent enrollment. The agency may require a recipient to use
719 the capitated managed care network’s grievance process as
720 specified in paragraph (3)(q) prior to the agency’s
721 determination of cause, except in cases in which immediate risk
722 of permanent damage to the recipient’s health is alleged. The
723 grievance process, when used, must be completed in time to
724 permit the recipient to disenroll no later than the first day of
725 the second month after the month the disenrollment request was
726 made. If the capitated managed care network, as a result of the
727 grievance process, approves an enrollee’s request to disenroll,
728 the agency is not required to make a determination in the case.
729 The agency must make a determination and take final action on a
730 recipient’s request so that disenrollment occurs no later than
731 the first day of the second month after the month the request
732 was made. If the agency fails to act within the specified
733 timeframe, the recipient’s request to disenroll is deemed to be
734 approved as of the date agency action was required. Recipients
735 who disagree with the agency’s finding that cause does not exist
736 for disenrollment shall be advised of their right to pursue a
737 Medicaid fair hearing to dispute the agency’s finding.
738 (f) The agency shall apply for federal waivers from the
739 Centers for Medicare and Medicaid Services to lock eligible
740 Medicaid recipients into a capitated managed care network for 12
741 months after an open enrollment period. After 12 months of
742 enrollment, a recipient may select another capitated managed
743 care network. However, nothing shall prevent a Medicaid
744 recipient from changing primary care providers within the
745 capitated managed care network during the 12-month period.
746 (g) The agency shall apply for federal waivers from the
747 Centers for Medicare and Medicaid Services to allow recipients
748 to purchase health care coverage through an employer-sponsored
749 health insurance plan instead of through a Medicaid-certified
750 plan. This provision shall be known as the opt-out option.
751 1. A recipient who chooses the Medicaid opt-out option
752 shall have an opportunity for a specified period of time, as
753 authorized under a waiver granted by the Centers for Medicare
754 and Medicaid Services, to select and enroll in a Medicaid
755 certified plan. If the recipient remains in the employer
756 sponsored plan after the specified period, the recipient shall
757 remain in the opt-out program for at least 1 year or until the
758 recipient no longer has access to employer-sponsored coverage,
759 until the employer’s open enrollment period for a person who
760 opts out in order to participate in employer-sponsored coverage,
761 or until the person is no longer eligible for Medicaid,
762 whichever time period is shorter.
763 2. Notwithstanding any other provision of this section,
764 coverage, cost sharing, and any other component of employer
765 sponsored health insurance shall be governed by applicable state
766 and federal laws.
767 (5) This section authorizes does not authorize the agency
768 to seek an extension amendment and to continue operation
769 implement any provision of the s. 1115 of the Social Security
770 Act experimental, pilot, or demonstration project waiver to
771 reform the state Medicaid program in any part of the state other
772 than the two geographic areas specified in this section unless
773 approved by the Legislature.
774 (6) The agency shall develop and submit for approval
775 applications for waivers of applicable federal laws and
776 regulations as necessary to extend and expand implement the
777 managed care pilot project as defined in this section. The
778 agency shall seek public input on the waiver and post all waiver
779 applications under this section on its Internet website for 30
780 days before submitting the applications to the United States
781 Centers for Medicare and Medicaid Services. The 30 days shall
782 commence with the initial posting and must conclude 30 days
783 prior to approval by the United States Centers for Medicare and
784 Medicaid Services. All waiver applications shall be provided for
785 review and comment to the appropriate committees of the Senate
786 and House of Representatives for at least 10 working days prior
787 to submission. All waivers submitted to and approved by the
788 United States Centers for Medicare and Medicaid Services under
789 this section must be approved by the Legislature. Federally
790 approved waivers must be submitted to the President of the
791 Senate and the Speaker of the House of Representatives for
792 referral to the appropriate legislative committees. The
793 appropriate committees shall recommend whether to approve the
794 implementation of any waivers to the Legislature as a whole. The
795 agency shall submit a plan containing a recommended timeline for
796 implementation of any waivers and budgetary projections of the
797 effect of the pilot program under this section on the total
798 Medicaid budget for the 2006-2007 through 2009-2010 state fiscal
799 years. This implementation plan shall be submitted to the
800 President of the Senate and the Speaker of the House of
801 Representatives at the same time any waivers are submitted for
802 consideration by the Legislature. The agency may implement the
803 waiver and special terms and conditions numbered 11-W-00206/4,
804 as approved by the federal Centers for Medicare and Medicaid
805 Services. If the agency seeks approval by the Federal Government
806 of any modifications to these special terms and conditions, the
807 agency must provide written notification of its intent to modify
808 these terms and conditions to the President of the Senate and
809 the Speaker of the House of Representatives at least 15 days
810 before submitting the modifications to the Federal Government
811 for consideration. The notification must identify all
812 modifications being pursued and the reason the modifications are
813 needed. Upon receiving federal approval of any modifications to
814 the special terms and conditions, the agency shall provide a
815 report to the Legislature describing the federally approved
816 modifications to the special terms and conditions within 7 days
817 after approval by the Federal Government.
818 Section 3. Paragraph (b) of subsection (4) of section
819 409.912, Florida Statutes, is amended, and paragraph (d) of
820 subsection (4) of that section is reenacted, to read:
821 409.912 Cost-effective purchasing of health care.—The
822 agency shall purchase goods and services for Medicaid recipients
823 in the most cost-effective manner consistent with the delivery
824 of quality medical care. To ensure that medical services are
825 effectively utilized, the agency may, in any case, require a
826 confirmation or second physician’s opinion of the correct
827 diagnosis for purposes of authorizing future services under the
828 Medicaid program. This section does not restrict access to
829 emergency services or poststabilization care services as defined
830 in 42 C.F.R. part 438.114. Such confirmation or second opinion
831 shall be rendered in a manner approved by the agency. The agency
832 shall maximize the use of prepaid per capita and prepaid
833 aggregate fixed-sum basis services when appropriate and other
834 alternative service delivery and reimbursement methodologies,
835 including competitive bidding pursuant to s. 287.057, designed
836 to facilitate the cost-effective purchase of a case-managed
837 continuum of care. The agency shall also require providers to
838 minimize the exposure of recipients to the need for acute
839 inpatient, custodial, and other institutional care and the
840 inappropriate or unnecessary use of high-cost services. The
841 agency shall contract with a vendor to monitor and evaluate the
842 clinical practice patterns of providers in order to identify
843 trends that are outside the normal practice patterns of a
844 provider’s professional peers or the national guidelines of a
845 provider’s professional association. The vendor must be able to
846 provide information and counseling to a provider whose practice
847 patterns are outside the norms, in consultation with the agency,
848 to improve patient care and reduce inappropriate utilization.
849 The agency may mandate prior authorization, drug therapy
850 management, or disease management participation for certain
851 populations of Medicaid beneficiaries, certain drug classes, or
852 particular drugs to prevent fraud, abuse, overuse, and possible
853 dangerous drug interactions. The Pharmaceutical and Therapeutics
854 Committee shall make recommendations to the agency on drugs for
855 which prior authorization is required. The agency shall inform
856 the Pharmaceutical and Therapeutics Committee of its decisions
857 regarding drugs subject to prior authorization. The agency is
858 authorized to limit the entities it contracts with or enrolls as
859 Medicaid providers by developing a provider network through
860 provider credentialing. The agency may competitively bid single
861 source-provider contracts if procurement of goods or services
862 results in demonstrated cost savings to the state without
863 limiting access to care. The agency may limit its network based
864 on the assessment of beneficiary access to care, provider
865 availability, provider quality standards, time and distance
866 standards for access to care, the cultural competence of the
867 provider network, demographic characteristics of Medicaid
868 beneficiaries, practice and provider-to-beneficiary standards,
869 appointment wait times, beneficiary use of services, provider
870 turnover, provider profiling, provider licensure history,
871 previous program integrity investigations and findings, peer
872 review, provider Medicaid policy and billing compliance records,
873 clinical and medical record audits, and other factors. Providers
874 shall not be entitled to enrollment in the Medicaid provider
875 network. The agency shall determine instances in which allowing
876 Medicaid beneficiaries to purchase durable medical equipment and
877 other goods is less expensive to the Medicaid program than long
878 term rental of the equipment or goods. The agency may establish
879 rules to facilitate purchases in lieu of long-term rentals in
880 order to protect against fraud and abuse in the Medicaid program
881 as defined in s. 409.913. The agency may seek federal waivers
882 necessary to administer these policies.
883 (4) The agency may contract with:
884 (b) An entity that is providing comprehensive behavioral
885 health care services to certain Medicaid recipients through a
886 capitated, prepaid arrangement pursuant to the federal waiver
887 provided for by s. 409.905(5). Such entity must be licensed
888 under chapter 624, chapter 636, or chapter 641, or authorized
889 under paragraph (c) or paragraph (d), and must possess the
890 clinical systems and operational competence to manage risk and
891 provide comprehensive behavioral health care to Medicaid
892 recipients. As used in this paragraph, the term “comprehensive
893 behavioral health care services” means covered mental health and
894 substance abuse treatment services that are available to
895 Medicaid recipients. The secretary of the Department of Children
896 and Family Services shall approve provisions of procurements
897 related to children in the department’s care or custody before
898 enrolling such children in a prepaid behavioral health plan. Any
899 contract awarded under this paragraph must be competitively
900 procured. In developing the behavioral health care prepaid plan
901 procurement document, the agency shall ensure that the
902 procurement document requires the contractor to develop and
903 implement a plan to ensure compliance with s. 394.4574 related
904 to services provided to residents of licensed assisted living
905 facilities that hold a limited mental health license. Except as
906 provided in subparagraph 8., and except in counties where the
907 Medicaid managed care pilot program is authorized pursuant to s.
908 409.91211, the agency shall seek federal approval to contract
909 with a single entity meeting these requirements to provide
910 comprehensive behavioral health care services to all Medicaid
911 recipients not enrolled in a Medicaid managed care plan
912 authorized under s. 409.91211, a provider service network
913 authorized under paragraph (d), or a Medicaid health maintenance
914 organization in an AHCA area. In an AHCA area where the Medicaid
915 managed care pilot program is authorized pursuant to s.
916 409.91211 in one or more counties, the agency may procure a
917 contract with a single entity to serve the remaining counties as
918 an AHCA area or the remaining counties may be included with an
919 adjacent AHCA area and are subject to this paragraph. Each
920 entity must offer a sufficient choice of providers in its
921 network to ensure recipient access to care and the opportunity
922 to select a provider with whom they are satisfied. The network
923 shall include all public mental health hospitals. To ensure
924 unimpaired access to behavioral health care services by Medicaid
925 recipients, all contracts issued pursuant to this paragraph must
926 require 80 percent of the capitation paid to the managed care
927 plan, including health maintenance organizations and capitated
928 provider service networks, to be expended for the provision of
929 behavioral health care services. If the managed care plan
930 expends less than 80 percent of the capitation paid for the
931 provision of behavioral health care services, the difference
932 shall be returned to the agency. The agency shall provide the
933 plan with a certification letter indicating the amount of
934 capitation paid during each calendar year for behavioral health
935 care services pursuant to this section. The agency may reimburse
936 for substance abuse treatment services on a fee-for-service
937 basis until the agency finds that adequate funds are available
938 for capitated, prepaid arrangements.
939 1. By January 1, 2001, the agency shall modify the
940 contracts with the entities providing comprehensive inpatient
941 and outpatient mental health care services to Medicaid
942 recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
943 Counties, to include substance abuse treatment services.
944 2. By July 1, 2003, the agency and the Department of
945 Children and Family Services shall execute a written agreement
946 that requires collaboration and joint development of all policy,
947 budgets, procurement documents, contracts, and monitoring plans
948 that have an impact on the state and Medicaid community mental
949 health and targeted case management programs.
950 3. Except as provided in subparagraph 8., by July 1, 2006,
951 the agency and the Department of Children and Family Services
952 shall contract with managed care entities in each AHCA area
953 except area 6 or arrange to provide comprehensive inpatient and
954 outpatient mental health and substance abuse services through
955 capitated prepaid arrangements to all Medicaid recipients who
956 are eligible to participate in such plans under federal law and
957 regulation. In AHCA areas where eligible individuals number less
958 than 150,000, the agency shall contract with a single managed
959 care plan to provide comprehensive behavioral health services to
960 all recipients who are not enrolled in a Medicaid health
961 maintenance organization, a provider service network authorized
962 under paragraph (d), or a Medicaid capitated managed care plan
963 authorized under s. 409.91211. The agency may contract with more
964 than one comprehensive behavioral health provider to provide
965 care to recipients who are not enrolled in a Medicaid capitated
966 managed care plan authorized under s. 409.91211, a provider
967 service network authorized under paragraph (d), or a Medicaid
968 health maintenance organization in AHCA areas where the eligible
969 population exceeds 150,000. In an AHCA area where the Medicaid
970 managed care pilot program is authorized pursuant to s.
971 409.91211 in one or more counties, the agency may procure a
972 contract with a single entity to serve the remaining counties as
973 an AHCA area or the remaining counties may be included with an
974 adjacent AHCA area and shall be subject to this paragraph.
975 Contracts for comprehensive behavioral health providers awarded
976 pursuant to this section shall be competitively procured. Both
977 for-profit and not-for-profit corporations are eligible to
978 compete. Managed care plans contracting with the agency under
979 subsection (3) or paragraph (d), shall provide and receive
980 payment for the same comprehensive behavioral health benefits as
981 provided in AHCA rules, including handbooks incorporated by
982 reference. In AHCA area 11, the agency shall contract with at
983 least two comprehensive behavioral health care providers to
984 provide behavioral health care to recipients in that area who
985 are enrolled in, or assigned to, the MediPass program. One of
986 the behavioral health care contracts must be with the existing
987 provider service network pilot project, as described in
988 paragraph (d), for the purpose of demonstrating the cost
989 effectiveness of the provision of quality mental health services
990 through a public hospital-operated managed care model. Payment
991 shall be at an agreed-upon capitated rate to ensure cost
992 savings. Of the recipients in area 11 who are assigned to
993 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
994 MediPass-enrolled recipients shall be assigned to the existing
995 provider service network in area 11 for their behavioral care.
996 4. By October 1, 2003, the agency and the department shall
997 submit a plan to the Governor, the President of the Senate, and
998 the Speaker of the House of Representatives which provides for
999 the full implementation of capitated prepaid behavioral health
1000 care in all areas of the state.
1001 a. Implementation shall begin in 2003 in those AHCA areas
1002 of the state where the agency is able to establish sufficient
1003 capitation rates.
1004 b. If the agency determines that the proposed capitation
1005 rate in any area is insufficient to provide appropriate
1006 services, the agency may adjust the capitation rate to ensure
1007 that care will be available. The agency and the department may
1008 use existing general revenue to address any additional required
1009 match but may not over-obligate existing funds on an annualized
1011 c. Subject to any limitations provided in the General
1012 Appropriations Act, the agency, in compliance with appropriate
1013 federal authorization, shall develop policies and procedures
1014 that allow for certification of local and state funds.
1015 5. Children residing in a statewide inpatient psychiatric
1016 program, or in a Department of Juvenile Justice or a Department
1017 of Children and Family Services residential program approved as
1018 a Medicaid behavioral health overlay services provider may not
1019 be included in a behavioral health care prepaid health plan or
1020 any other Medicaid managed care plan pursuant to this paragraph.
1021 6. In converting to a prepaid system of delivery, the
1022 agency shall in its procurement document require an entity
1023 providing only comprehensive behavioral health care services to
1024 prevent the displacement of indigent care patients by enrollees
1025 in the Medicaid prepaid health plan providing behavioral health
1026 care services from facilities receiving state funding to provide
1027 indigent behavioral health care, to facilities licensed under
1028 chapter 395 which do not receive state funding for indigent
1029 behavioral health care, or reimburse the unsubsidized facility
1030 for the cost of behavioral health care provided to the displaced
1031 indigent care patient.
1032 7. Traditional community mental health providers under
1033 contract with the Department of Children and Family Services
1034 pursuant to part IV of chapter 394, child welfare providers
1035 under contract with the Department of Children and Family
1036 Services in areas 1 and 6, and inpatient mental health providers
1037 licensed pursuant to chapter 395 must be offered an opportunity
1038 to accept or decline a contract to participate in any provider
1039 network for prepaid behavioral health services.
1040 8. All Medicaid-eligible children, except children in area
1041 1 and children in Highlands County, Hardee County, Polk County,
1042 or Manatee County of area 6, that are open for child welfare
1043 services in the HomeSafeNet system, shall receive their
1044 behavioral health care services through a specialty prepaid plan
1045 operated by community-based lead agencies through a single
1046 agency or formal agreements among several agencies. The
1047 specialty prepaid plan must result in savings to the state
1048 comparable to savings achieved in other Medicaid managed care
1049 and prepaid programs. Such plan must provide mechanisms to
1050 maximize state and local revenues. The specialty prepaid plan
1051 shall be developed by the agency and the Department of Children
1052 and Family Services. The agency may seek federal waivers to
1053 implement this initiative. Medicaid-eligible children whose
1054 cases are open for child welfare services in the HomeSafeNet
1055 system and who reside in AHCA area 10 are exempt from the
1056 specialty prepaid plan upon the development of a service
1057 delivery mechanism for children who reside in area 10 as
1058 specified in s. 409.91211(3)(dd).
1059 (d) A provider service network may be reimbursed on a fee
1060 for-service or prepaid basis. A provider service network which
1061 is reimbursed by the agency on a prepaid basis shall be exempt
1062 from parts I and III of chapter 641, but must comply with the
1063 solvency requirements in s. 641.2261(2) and meet appropriate
1064 financial reserve, quality assurance, and patient rights
1065 requirements as established by the agency. Medicaid recipients
1066 assigned to a provider service network shall be chosen equally
1067 from those who would otherwise have been assigned to prepaid
1068 plans and MediPass. The agency is authorized to seek federal
1069 Medicaid waivers as necessary to implement the provisions of
1070 this section. Any contract previously awarded to a provider
1071 service network operated by a hospital pursuant to this
1072 subsection shall remain in effect for a period of 3 years
1073 following the current contract expiration date, regardless of
1074 any contractual provisions to the contrary. A provider service
1075 network is a network established or organized and operated by a
1076 health care provider, or group of affiliated health care
1077 providers, including minority physician networks and emergency
1078 room diversion programs that meet the requirements of s.
1079 409.91211, which provides a substantial proportion of the health
1080 care items and services under a contract directly through the
1081 provider or affiliated group of providers and may make
1082 arrangements with physicians or other health care professionals,
1083 health care institutions, or any combination of such individuals
1084 or institutions to assume all or part of the financial risk on a
1085 prospective basis for the provision of basic health services by
1086 the physicians, by other health professionals, or through the
1087 institutions. The health care providers must have a controlling
1088 interest in the governing body of the provider service network
1090 Section 4. This act shall take effect July 1, 2010.