HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 43 Medicaid Behavioral Health Provider Performance
SPONSOR(S): Select Committee on Health Innovation, Silvers and others
TIED BILLS: IDEN./SIM. BILLS:
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Select Committee on Health Innovation 15 Y, 0 N, As CS Lloyd Calamas
2) Health Care Appropriations Subcommittee 15 Y, 0 N Smith Clark
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. However, AHCA does not establish network adequacy standard for inpatient psychiatric care. Current
law requires AHCA to test managed care plan networks for network adequacy, but does not specify how AHCA must do
so. While current law requires AHCA to ensure access, current net work standards and testing methods do not adequately
ensure access to care.
CS/HB 43 establishes a more specific framework for Medicaid managed care network adequacy for behavioral health
care services. The bill modifies the quality selection criteria for provider networks to ensure that Medicaid enrollee access
to behavioral health care providers is included in future procurement processes.
For ongoing managed care plan performance, the bill requires AHCA to establish network adequacy standards for each
type of behavioral health provider, including facilities, and to establish maximum wait times for appointments or
admissions by each provider type. These network standards must exceed federal minimum standards. The bill also
requires AHCA to be more rigorous in testing plan provider networks, by requiring AHCA to contract with an independent
vendor to do this work, and to publish quarterly and annual reports on the results of network testing by plan and region.
The bill also requires AHCA to establish and enforce plan-specific, year-over-year, clinical performance goals in
behavioral health. AHCA must use each plan’s federal behavioral health Healthcare Effectiveness Data and Information
Set (HEDIS) score in the first full year of the contract as the bas eline for improvement. Similarly, the bill requires AHCA to
establish behavioral health-specific metrics for plans to qualify for an achieved savings rebate.
Finally, the bill requires AHCA to report to the Legislature annually, beginning October 1, 2024, on Medicaid-enrolled
children who are high-utilizers of crisis stabilization services and on plan network testing and performance data based on
the measures established by AHCA under the bill. This expands and recodifies a similar report previously requir ed by law,
which ended in 2022.
AHCA must amend managed care plan contracts by January 1, 2025, to implement the bill’s requirements.
The bill has an indeterminate, likely insignificant negative fiscal impact on AHCA, and no impact on local government.
The bill provides an effective date of July 1, 2024.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
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 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 almost 5 million low-income individuals, including approximately
2.3 million children, or almost half 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, Medicaid Eligibles Report (December 31, 2023) available at https://ahca.myflorida.com/medicaid/medicaid-
finance-and-analytics/medicaid-data-analytics/medicaid-eligibles-reports (last viewed January 25, 2024).
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 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
Behavioral Health 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 Medicaid, and by the
behavioral health safety net program for people without other coverage administered by the
Department of Children and Families (DCF)12.
Child Baker Act Data
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. The table shows
indicates the significant annual increase in involuntary examination of minors between 2001 and 2017,
which rose from 14,997 in 2001 to 36,078 in 2017. The rate of child examinations also rose at a much
higher rate than that in the general population: a 140% increase in that time period.
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. Involuntary admissions are governed by the Florida “Baker Act”. For involuntary patients the receiving facility must examine the
patient w ithin 72 hours of arrival. During that 72 hours, an involuntary patient must be examined by a physician or a clinic al psychologist, or by a
psychiatric nurse performing w ithin 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 w ithin 12 hours. By the end of that 72-hour examination period, one of the
follow ing must happen:
 The patient must be released;
 The patient must be released for voluntary outpatient treatment;
 The patient must consent to voluntary inpatient admission; 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 statew ide system of safety -net services for substance abuse and mental health (SAMH) prevention,
treatment and recovery for children and adults w ho 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.
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 2017 DCF Task Force
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
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
2019-2021 DCF Reporting
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.
13
Ch. 2017-151, Law s 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 view ed January 25, 2024).
15
Id.
16
Ch. 2019-134, Law s of Florida.
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 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.
Involuntary Examinations in Florida:
Rate per 100,000
1400
1200
1000
800
600
400
200
0
All Ages Minors (>18)
The 2021 report made similar findings, and updated the data. 18
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 January 25, 2024).
18
Florida Department of Children and Families, Report on Involuntary Examination of Minors, November 2021, Report on Involuntary Examination of
Minors 2021.pdf (myflfamilies.com) (last view ed January 25, 2024).
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 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
Child Baker Act High Utilizer Project
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 act 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 A “high utilizer”
was defined by the Department and the Agency as children or adolescents under 18 years of age with
three or more admissions into a crisis stabilization unit or an inpatient psychiatric hospital within 180
days.21
This reporting documented the fact that the vast majority of high utilizer children are covered by
Medicaid, rather than by the Department safety net program, as indicated by the table below.22
This reporting broke out the repeat child hospitalizations by Medicaid managed care pl