October 15, 2019
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       Florida Senate - 2010                             CS for SB 1484
       
       
       
       By the Committee on Health and Human Services Appropriations;
       and Senator Peaden
       
       
       
       603-03264-10                                          20101484c1
    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.
   37  
   38  Be It Enacted by the Legislature of the State of Florida:
   39  
   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
  134  (25) (24).
  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
  201  2011.
  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
  241  individuals;
  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
  249  costs;
  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
  265  ensuring:
  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
  379  provided.
  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
  422  timeframe.
  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
  464  performed.
  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
  471  practitioner.
  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
  518  institutions.
  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
  558  investigations.
  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
  668  criteria:
  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
  681  residence.
  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
  686  unit.
  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
 1010  basis.
 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
 1089  organization.
 1090         Section 4. This act shall take effect July 1, 2010.

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