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.
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 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.
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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
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 establish ed protocol with a
psychiatrist at a facility to determine if the criteria for involuntary services are met. If the patient is a minor, the exam ination
must be initiated within 12 hours. By the end of that 72-hour examination period, one of the following m ust 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.
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 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.
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 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.
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
16
Ch. 2019-134, Laws of Florida.
17Florida 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, Novemb er 2021,
https://www.usf.edu/cbcs/baker-act/documents/dcf_oddyearreport_2021.pdf (last viewed March 26, 2023).
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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
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.
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 Children < 19 Yrs. Identified as High Utilizers of CSU/ Inpatient Behavioral Health Services by Health Plan
MMA Health Plan as of June 2022 Count of Children High 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