This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h1457a.HRS
DATE: 3/28/2023
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 1457 Medicaid Behavioral Health Provider Performance
SPONSOR(S): Silvers
TIED BILLS: IDEN./SIM. BILLS: SB 1652
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee 14 Y, 0 N Calamas McElroy
2) Health Care Appropriations Subcommittee
3) Health & Human Services Committee
SUMMARY ANALYSIS
Florida has experienced a significant increase in psychiatric crisis hospitalizations of children and teens in
recent years, and an increase in those children being repeatedly hospitalized in the same year. The Florida
Medicaid program has a significant role in behavioral health care because it insures a disproportionate share of
the children repeatedly hospitalized for behavioral health problems.
Medicaid managed care plans must meet standards set by the Agency for Health Care Administration (AHCA)
for provider network adequacy; that is, for a sufficient number, type and location of health care providers to
meet the needs of a plan’s enrollees. Current law requires AHCA to test managed care plan networks, but
does not specify that AHCA must establish standards for all types of behavioral health providers. While current
law requires AHCA to ensure access, current network testing methods do not address access.
HB 1457 increases Medicaid requirements for managed care plan behavioral health performance for children.
The bill requires AHCA to establish network requirements for each type of behavioral health provider serving
Medicaid enrollees, and improve its testing of behavioral health provider networks by including provider-
specific data on access timelines.
The bill requires AHCA to establish specific, outcome-based, performance measures for Medicaid managed
care plans to reduce high-utilization of crisis stabilization services by children and teenagers. The bill requires
the measures, at a minimum, to require plan-specific measures for year-over-year improvement.
Finally, the bill requires AHCA to report to the legislature annually, beginning October 1, 2023, on Medicaid-
enrolled children who are high-utilizers of crisis stabilization services. The report must include demographic
and geographic data, plan network testing data, and plan performance data based on the outcome
performance measures established by AHCA under the bill. The report must also include an analysis of AHCA
contract mechanisms for enforcing or incentivizing plan compliance with the requirements of the bill, and data
on the use of those or other mechanisms by the agency, and any other actions taken by the agency to improve
behavioral health outcomes for children in Medicaid.
The bill requires AHCA to amend managed care plan contracts by January 1, 2024, to reflect these changes.
The bill has an indeterminate, insignificant, negative fiscal impact on AHCA, and none on local government.
The bill provides an effective date of July 1, 2023. STORAGE NAME: h1457a.HRS PAGE: 2
DATE: 3/28/2023
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Florida Medicaid
Medicaid is the health care safety net for low-income Floridians. Medicaid is a partnership of the federal
and state governments established to provide coverage for health services for eligible persons. The
program is administered by the Agency for Health Care Administration (AHCA) and financed by federal
and state funds.
The structure of each state’s Medicaid program varies and what states must pay for is largely
determined by the federal government, as a condition of receiving federal funds.
1
Federal law sets the
amount, scope, and duration of services offered in the program, among other requirements. These
federal requirements create an entitlement that comes with constitutional due process protections. The
entitlement means that two parts of the Medicaid cost equation – people and utilization – are largely
predetermined for the states. The federal government sets the minimum mandatory populations to be
included in every state Medicaid program. The federal government also sets the minimum mandatory
benefits to be covered in every state Medicaid program.
2
States can add benefits, with federal approval.
Florida has added many optional benefits, including prescription drugs, adult dental services, and
dialysis.
3
States have some flexibility in the provision of Medicaid services. Section 1915(b) of the Social Security
Act provides authority for the Secretary of the U.S. Department of Health and Human Services (HHS) to
waive requirements to the extent that he or she “finds it to be cost-effective and efficient and not
inconsistent with the purposes of this title.” Section 1115 of the Social Security Act allows states to
implement demonstrations of innovative service delivery systems that improve care, increase efficiency,
and reduce costs. These laws allow HHS to waive federal requirements to expand populations or
services, or to try new ways of service delivery.
Florida operates under a Section 1115 waiver to use a comprehensive managed care delivery model
for primary and acute care services, the Statewide Medicaid Managed Care (SMMC) Managed Medical
Assistance (MMA) program.
4
Florida also has a waiver under Sections 1915(b) and (c) of the Social
Security Act to operate the SMMC Long-Term Care (LTC) program.
5
The Florida Medicaid program covers over 5.5 million low-income individuals, including approximately
2.5 million children, or 54%, of the children in Florida.
6
Medicaid Behavioral Health Services
Medicaid provides coverage for behavioral health services, including both services in the community
and inpatient hospitalization. Community services include crisis stabilization, transitional day services,
therapeutic behavioral on-site services, psychosocial rehabilitation, medication and medication
management, behavioral health overlay services, and community supports for independent living,
among other services.
1
Title 42 U.S.C. §§ 1396-1396w-5; Title 42 C.F.R. Part 430-456 (§§ 430.0-456.725) (2016).
2
S. 409.905, F.S.
3
S. 409.906, F.S.
4
S. 409.964, F.S.
5
Id.
6
Agency for Health Care Administration, Presentation to the House Healthcare Regulation Subcommittee, Jan. 18, 2023. STORAGE NAME: h1457a.HRS PAGE: 3
DATE: 3/28/2023
For a child to obtain covered behavioral health services, a practitioner must formally assess the child’s
mental health status, substance use concerns, functional capacity, strengths, and service needs, to
develop a plan of care.
7
Federal law requires state Medicaid programs to provide all medically necessary services needed by a
child, under the “Early and Periodic Screening, Diagnosis and Treatment” standard established by the
federal Social Security Act.
8
This applies even to services not formally covered, and to services needed
beyond the scope or duration of coverage.
9
Crisis Stabilization
Crisis Stabilization Units (CSUs) are specialized public receiving facilities that receive state funding to
provide services to individuals showing acute mental health disorders. CSUs screen, assess, and admit
for stabilization individuals who voluntarily present themselves to the unit, as well as individuals who
are brought to the unit on an involuntary basis.
10
CSUs provide patients with 24-hour observation,
medication prescribed by a physician or psychiatrist, and other appropriate services.
11
The purpose of a crisis stabilization unit is to stabilize and redirect a client to the most appropriate and
least restrictive community setting available, consistent with the client’s needs.
Crisis stabilization services are covered by commercial health insurance, by the behavioral
health safety net program administered by the Department of Children and Families (for people
without other coverage)
12
, and by Medicaid.
High Utilizer Project
Recent years have seen a significant increase in the number of people requiring mental health crisis
stabilization – particularly children and teenagers – as indicated by the table below.
7
Agency for Health Care Administration, Community Behavioral Health Services Coverage and Limitations Handbook,
March 2014, p. 2-3.
8
Title 42 U.S.C. 1396(d).
9
See, e.g., Agency for Health Care Administration, Behavioral Health Therapy Services Coverage Policy, Nov. 2019, p. 3.
10
S. 394.875(1)(a), F.S. Involutary admissions are governed by the Florida “Baker Act”. For involuntary patients the receiving
facility must examine the patient within 72 hours of arrival. During that 72 hours, an involuntary patient must be examined by a
physician or a clinical psychologist, or by a psychiatric nurse performing within the framework of an established protocol with a
psychiatrist at a facility to determine if the criteria for involuntary services are met. If the patient is a minor, the examination
must be initiated within 12 hours. By the end of that 72-hour examination period, one of the following must happen:
The patient must be released;
The patient must be released for voluntary outpatient treatment;
The patient must give express and informed consent to a placement as a voluntary patient and admitted as a
voluntary patient; or
A petition for involuntary placement must be filed in circuit court for involuntary outpatient or inpatient treatment.
11
Id.
12
See, ch. 394 and ch. 397, F.S. DCF administers a statewide system of safety-net services for substance abuse and mental health
(SAMH) prevention, treatment and recovery for children and adults who are otherwise unable to obtain these services. SAMH programs
include a range of prevention, acute interventions (e.g. crisis stabilization), residential treatment, transitional housing, outpatient
treatment, and recovery support services. Services are provided based upon state and federally-established priority populations. STORAGE NAME: h1457a.HRS PAGE: 4
DATE: 3/28/2023
In 2017, the Legislature created a task force within DCF
13
to address the issue of involuntary examination
of minors age 17 years or younger, specifically by:
14
Analyzing data on the initiation of involuntary examinations of minors;
Researching the root causes of and trends in such involuntary examinations;
Identifying and evaluating options for expediting the examination process; and
Identifying recommendations for encouraging alternatives to or eliminating inappropriate initiations
of such examinations.
The task force found that specific causes of increases in involuntary examinations of children are unknown.
Possible factors cited in the task force report include an increase in mental health concerns, social
stressors, and a lack of availability of mental health services.
15
13
Ch. 2017-151, Laws of Florida.
14
Florida Department of Children and Families, Task Force Report on Involuntary Examination of Minors, (Nov. 2017),
https://www.myflfamilies.com/service-programs/samh/publications/docs/S17-005766-
TASK%20FORCE%20ON%20INVOLUNTARY%20EXAMINATION%20OF%20MINORS.pdf (last visited March 26, 2023).
15
Id. STORAGE NAME: h1457a.HRS PAGE: 5
DATE: 3/28/2023
As a follow up to the 2017 task force report, in 2019, the Legislature instructed DCF to prepare a report
on the initiation of involuntary examinations of minors age 17 years and younger and submit it by
November 1 of each odd numbered year.
16
The 2019 report, revealed that some crisis stabilization units are not meeting the needs of children and
adolescents with significant behavioral health needs, contributing to multiple exams.
The 2019 report found there were 205,781 involuntary examinations in FY 2017-2018, 36,078 of which
were of minors.
17
From FY 2013-2014 to FY 2017-2018, statewide involuntary examinations increased
18.85% for children. Children had a larger increase in examinations compared to young adults ages 18-24
(14.04%) and adults (12.49%). Additionally, 22.61% of minors had multiple involuntary examinations in FY
2017-2018: up to 19 involuntary examinations in a single year. DCF identified 21 minors who had more
than ten involuntary examinations in FY 2017-2018, with a combined total of 285 examinations. DCF’s
review of medical records found:
Most initiations were a result of minors harming themselves and were predominately initiated by law
enforcement (88%);
Many minors were involved in the child welfare system and most experienced significant family
dysfunction;
Most experienced multiple traumas such as abuse, bullying, exposure to violence, parental
incarceration, and parental substance abuse and mental health issues;
Most had behavioral disorders of childhood, such as ADHD or Oppositional Defiant Disorder,
followed by mood disorders, followed by anxiety disorders;
Most involuntary examinations were initiated at home or at a behavioral health provider; and
Discharge planning and care coordination by the receiving facilities was not adequate enough to
meet the child’s needs.
The 2019 report documented the significant increase in the rate of involuntary examinations of children,
from a rate (per 100,000 population) of 547 in 2001 to a rate of 1,186 in 2018.
The 2021 report made similar findings, and updated the data.
18
16
Ch. 2019-134, Laws of Florida.
17
Florida Department of Children and Families, Report on Involuntary Examination of Minors, 2019, (Nov. 2019), p. 25,
https://www.usf.edu/cbcs/baker-act/documents/dcfoddyearreport2019.pdf (last visited March 26, 2023).
18
Florida Department of Children and Families, Report on Involuntary Examination of Minors, November 2021,
https://www.usf.edu/cbcs/baker-act/documents/dcf_oddyearreport_2021.pdf (last viewed March 26, 2023).
0
200
400
600
800
1000
1200
1400
Involuntary Examinations in Florida:
Rate per 100,000
All Ages Minors (>18) STORAGE NAME: h1457a.HRS PAGE: 6
DATE: 3/28/2023
The 2021 report noted that the vast majority of children with multiple crisis examinations in a year have
Medicaid coverage, which should have provided greater access to community care that would help the
children avoid the need for crisis care.
19
Following up on this work, the legislature in 2020 required DCF and AHCA to identify children and
adolescents who are the highest users of crisis stabilization and inpatient psychiatric hospitalization
services, collaboratively take action to meet the behavioral health needs of those children, and submit a
joint quarterly report during Fiscal Years 2020-2021 and 2021-2022 to the Legislature.
20
This reporting further documented the Medicaid share of the problem, as noted in the table below:
21
This reporting broke out the repeat child hospitalizations by Medicaid managed care plan, as indicated
in the table below. Note that the plans highlighted in yellow are specialty plans, have disproportionate
numbers of children in their enrollment cohort with serious trauma (as with the Sunshine Child Welfare
plan) or with serious mental illness (as with the Molina and Sunshine SMI plans), so higher rates would
be expected in those plans.
22
19
Id. at 11.
20
Ch. 2020-107, L.O.F.
21
Department of Children and Families and Agency for Health Care Administration, Presentation to the House
Subcommittee on Children, Families and Seniors, Feb. 8, 2023.
22
Id. STORAGE NAME: h1457a.HRS PAGE: 7
DATE: 3/28/2023
AHCA reported on efforts made by the plans to improve care, including assigning the children a case
manager, and reaching out to parents to offer more services. According to AHCA, more than one-third
of the parents contacted could not be reached or did not respond. In some instances, parents declined
case management or specific service offer
23
This may point to a need to address whole-family
problems in order to assist the child.
Medicaid Provider Networks
Current law requires AHCA to establish network adequacy requirements for the managed care plans to
meet when contracting with providers. Specifically, AHCA must establish standards for how many
providers, the type of providers, and the regional distribution of providers are necessary for each plan
to ensure access to care for the Medicaid recipients in their enrollment cohort. Each plan must
establish a database of contracted providers and information about them, and publish the database
online that allows Medicaid enrollees to compare provider availability to the network adequacy
standards.
24
Prior to 2020, Florida law did not expressly require the Medicaid program to test the provider networks,
to confirm accuracy and compliance with the network standards.
Provider Network Testing
In 2020, the legislature required the Medicaid program to conduct (or contract for) systematic and
continuous testing of the provider network databases to confirm accuracy. In addition, the legislature
required more intensive network adequacy testing for the network of behavioral health providers.
Section 409.967(2)(c), F.S., requires AHCA to systematically and continuously test the behavioral
health network to confirm:
1. That Medicaid behavioral health providers are accepting Medicaid patients; and
2. That Medicaid enrollees have access to behavioral health services.
AHCA implemented this requirement by conducting this testing in-house, as a desk review of the
provider databases, or by requiring the plans to test themselves. In addition, AHCA performs periodic
“secret shopper” testing by calling the provider offices and confirming
25
:
Whether the provider’s phone number and address listed in the database are correct;
Whether the provider is available to see patients at the location listed;
Whether the provider’s staff is aware that the provider is in the plan’s network; and
23
Id.
24
S. 490.967(2)(c)1., F.S.
25
Agency for Health Care Administration, Agency Prescribed Secret Shopper Template, on file with staff of the House
Subcommittee on Healthcare Regulation. MMA Health Plan as of June 2022Count of ChildrenHigh Utilizers Per 1,000 Enrollees
Aetna 2 0.02
Amerihealth 5 0.06
CCP 4 0.10
CMS Plan 49 0.57
FFS Provider 4 0.05
Humana 36 0.09
Molina 5 0.07
Molina - Serious Mental Illness* 15 3.42
Simply 34 0.08
Sunshine 142 0.14
Sunshine - Child Welfare* 129 3.33
Sunshine - Serious Mental Illness* 99 3.62
United 25 0.13
Vivida 1 0.06
Grand Total 550 0.21
Children < 19 Yrs. Identified as High Utilizers of CSU/ Inpatient Behavioral Health Services by Health Plan STORAGE NAME: h1457a.HRS PAGE: 8
DATE: 3/28/2023
Whether the provider is accepting new patients.
The agency tests the network of behavioral health care practitioners; it does not test the network of
inpatient psychiatric providers. It is unclear whether AHCA assesses need for inpatient services or
establishes network adequacy requirements for inpatient pediatric psychiatric beds or facilities.
This testing succeeds in identifying errors in the database and provider office confusion about
participation in the plan. For example, one test of Humana practitioners in 2021 identified several
providers with incorrect contact information, or which were no longer providing care at a listed location,
or were no longer accepting Humana patients, or could not be reached at all.
26
A similar 2021 exercise
across all plans for behavioral health practitioners identified several over 30 similar problems: provider
not found, provider not at the listed location, provider does not accept new patients, and address and
phone number problems.
27
The agency does not test how long it would take for a Medicaid enrollee to get an appointment with the
practitioner, or use other methods of measuring the level of access to care. The agency does not
compile or publish reports on in its current testing results, or on trends.
Effect of the Bill
HB 1457 increases Medicaid requirements for managed care plan provider network adequacy, related
to behavioral health providers.
Medicaid Provider Networks
Specifically, the bill requires AHCA to establish network requirements for each type of behavioral health
provider serving Medicaid enrollees, and specifically include both community-based and residential
providers. AHCA must amend current contracts by January 1, 2024, to reflect these changes.
In addition, the bill requires AHCA to improve testing of behavioral health provider networks by
including provider-specific data on access timelines.
The bill requires AHCA to contract to perform all network testing functions, rather than conduct it in-
house or rely on the managed care plans to test their provider directories, and provides that testing
should be conducted on the actual network, not merely the provider database or directory.
Medicaid Behavioral Health Performance Measures
The bill requires AHCA to establish specific, outcome-based, performance measures for Medicaid
managed care plans to reduce high-utilization of crisis stabilization services by children and teenagers.
The bill requires the measures, at a minimum, to require plan-specific measures for year-over-year
improvement.
AHCA must amend current managed care plan contracts by January 1, 2024, to reflect these changes.
Medicaid Performance Data
Finally, the bill requires AHCA to report to the legislature annually on Medicaid-enrolled children who
are high-utilizers of crisis stabilization services. The report must include demographic and geographic
data, and include plan performance data related to the outcome performance measures established by
26
Agency for Health Care Administration, Agency Prescribed Secret Shopper July 2021, on file with staff of the House
Subcommittee on Healthcare Regulation.
27
Agency for Health Care Administration, Agency Prescribed Secret Shopper, Q3 2021 Behavioral Health LDs, on file
with staff of the House Subcommittee on Healthcare Regulation STORAGE NAME: h1457a.HRS PAGE: 9
DATE: 3/28/2023
AHCA under the bill. In addition, the report must provide plan network testing data, including, at a
minimum, an assessment of access timelines and data trends.
The report must also include an analysis of managed care plan contract mechanisms for enforcing or
incentivizing compliance with the requirements of the bill, and data on the use of those or other
mechanisms by the agency, and any other actions taken by the agency to improve behavioral health
outcomes for children in Medicaid.
The first annual report is due October 1, 2023.
The bill provides an effective date of July 1, 2023.
B. SECTION DIRECTORY:
Section 1: Amends s. 409.967, F.S, related to managed care plan accountability.
Section 2: In an unnumbered section of law, requires certain contract amendments.
Section 3: In an unnumbered section of law, requires a certain report.
Section 4: Provides that the bill takes effect July 1, 2023.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill requirement for AHCA to contract for network adequacy testing has an unknown, but
insignificant, cost. Current contracted services allocations are sufficient to fund the requirements of
the bill.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
Medicaid managed care plans may reallocate the Medicaid capitated payment to improve performance
in behavioral health. Plans that improve performance will experience cost-avoidance savings due to
fewer repeat hospitalizations of children.
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not Applicable. This bill does not appear to affect county or municipal governments. STORAGE NAME: h1457a.HRS PAGE: 10
DATE: 3/28/2023
2. Other:
None.
B. RULE-MAKING AUTHORITY:
AHCA has sufficient rule-making authority to implement the provisions of the bill.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES