65D-31.001: Managing Entities
PURPOSE AND EFFECT: The purpose of this chapter is to implement the provisions of s.394.9082, Florida Statutes, by setting forth uniform standards and procedures for the qualifications, essential functions and operation of behavioral managing entities with regard to the development of an integrated community-based system of care.
SUMMARY: This rule addresses the management of the delivery of behavioral health services to persons who have mental health or substance abuse disorders. Areas addressed include development and oversight of comprehensive provider networks, uniform behavioral health services standards, continuous quality improvement and cost effective treatment to prevent unnecessary expenditures.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 394.9082(10) FS
LAW IMPLEMENTED: 394.9082 FS
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE SCHEDULED AND ANNOUNCED IN FAW.
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Gloria Henderson, Department of Children and Families, Mental Health Program, 1317 Winewood Boulevard, Building 6 Room 271, Tallahassee, Florida 32399
THE FULL TEXT OF THE PROPOSED RULE IS:
The purpose of this chapter is to implement the provisions of s. 394.9082,
Specific Authority 394.9082(10) FS. Law Implemented 394.9082 FS. History–New
65D-31.002 Definitions.
(1) “Behavioral Health Services” means mental health services and substance abuse prevention and treatment services are provided using state and federal funds as defined by Chapters 394 and 397 F.S.
(2) “Evidence-Based Practice” means substance abuse and mental health treatment practices that have been validated and supported by scientific evidence.
(3) “Geographic Area” means a county, circuit, region, or multi-regional area in the state. The area designated by the Department to be covered by managing entities and its provider service network.
(4) “Managing Entity” means a corporation that is organized in this state, is designated or filed as a nonprofit organization under s. 501(c)(3) of the Internal Revenue Service, and is under contract to the Department to manage the day-to-day operational delivery of behavioral health services through an organized system of care.
(5) “Provider Networks” means direct service agencies that are under contract with a managing entity and that together constitute a comprehensive array of emergency, acute care, residential, outpatient, recovery support, and consumer support services.
(6) “Readiness Assessment” means a formal review by the Department to determine the capability of a contractor to meet the responsibilities and administrative requirements of managing a provider network and a system of behavioral health services.
(7) “Stakeholder” means individuals served, family members, community agencies, the courts, law enforcement health agencies, local government, and others who have a demonstrated interest in the community’s substance abuse and mental health services.
(8) “System of Care” means substance abuse and mental health services that are coordinated and developed into a comprehensive and community-based network of services accessible and responsive to persons in need of substance abuse and mental health services, their families and to local stakeholders such as the courts, local government, law enforcement, health, and community agencies.
Specific Authority 394.9082(10) FS. Law Implemented 394.9082 FS. History–New
65D-31.003 Managing Entity Qualifications.
(1) A managing entity must be a corporation organized in the state of
(2) Designated as a non-profit organization under s. 501(c)(3) of the Internal Revenue Service.
(3) Demonstrate the capability and administrative capacity to effectively develop and manage a comprehensive service delivery system.
(4) Have a Board of Directors which shall, at a minimum, include individuals served, family members, appropriate community stakeholders, and organizations. Board membership shall include providers of substance abuse and mental health services. The Board shall have one representative of a private receiving facility as an ex officio member so long as there is a private receiving facility within the managing entity’s geographic area.
(5) Board members must be residents of the geographic area in which the managing entity operates.
Specific Authority 394.9082(10) FS. Law Implemented 394.9082 FS. History–New
65D-31.004 Functions of Managing Entities.
(1) System of care development and management.
(a) Must ensure that substance abuse and mental health services within their respective geographic areas are coordinated and developed into an integrated network of assessable services and is responsive to the needs of persons in need of service and their families.
(b) Must ensure that substance abuse and mental health services are responsive to the needs of the community and community stakeholders including the courts, community agencies, law enforcement, child welfare agencies and others who are reliant on mental health and substance abuse services as essential to their success.
(c) Must ensure the application of evidence-based practices by network providers through contracting requirements, program development and design, and the provision of training, technical assistance, and quality improvement activities.
(d) Develop effective and formal mechanisms for care management, continuity of care, and service coordination.
(e) Must develop Memorandum of Understanding or Interagency Agreement that address managing entity roles, relationship, and collaboration with the courts, law enforcement, health, and state and community agencies.
(2) Provider network management
(a) The managing entity is responsible for the development of a provider service network composed of direct service agencies under contract with a managing entity and that together provide a comprehensive array of emergency, acute care, residential, outpatient, recovery, consumer support and prevention services.
(b) The managing entity when contracting with providers are to ensure that agencies are qualified and capable of providing quality client services. The managing entity will develop policies, procedures, and practices that assure that network providers are complying with applicable laws, rules, regulations, and contract requirements.
(c) The managing entity will ensure that, within available resources, a comprehensive system of care is available within their respective geographic area that is accessible, co-occurring competent, and consists of a range of services that is responsive to the needs of persons receiving services and is responsive to the needs of the community.
(3) Financial Management
(a) The Managing Entity is responsible for the management, accountability, and efficient use of public funds by:
(b) Developing and negotiating rates with its network providers within the parameter established by the Department. Subject to approval by the Department, the managing entity may propose alternate payment methodologies such as case rates, capitation or other forms that demonstrate both accountability and efficiencies.
(c) Allocation of funds to providers consistent with departmentally approved allocation methodologies.
(d) Verifying the accuracy of provider invoices and ensuring timely payment of providers.
(e) Managing Department funding allocations to ensure that state and Federal requirements are met.
(f) Achieving efficiencies by the consolidation of provider operational functions including, but not limited to, data collection and analysis, administrative efficiencies, and group purchasing. Reinvesting funds gained by efficiencies into the system of care after achieving departmentally approved reserves and necessary infrastructure development.
(4) Planning
(a) The managing entity will participate in the departmental planning process of the state, regional, and circuit levels.
(b) A transition plan is required prior to a managing entity assuming responsibility for behavioral health services within a geographic area. The transition plan guidance will be provided by the Department.
(c) A three (3) year managing entity strategic plan is required to be submitted on a schedule that corresponds to the departmental statutorily required Substance Abuse and Mental Health Plan.
1. The Department will establish both the content requirements and due date of the Managing Entity Strategic Plan.
2. The Strategic Plan will be submitted by each managing entity and will address the strategic direction, goals, objectives, and activities to be accomplished during the three (3) year strategic planning cycle.
a. An annual business or operational plan is required to delineate progress in meeting the managing entity’s goals, objectives, and needs.
b. The Department will establish plan requirements and timeframes for the submission of the annual business plan.
c. All plans referenced in this section will be approved by the Managing Entity Board of Directors and include opportunities for public and stakeholder input.
d. All plans referenced in this section are subject to review and approval by the Department.
e. Approved managing entity plans will be provided to each of the County Commissioners of the counties served by the managing entity, as well as to any local government or agency that provides funding in support of behavioral health services within the managing entities geographic area.
(5) Data Collection, Analysis, and Reporting
(a) The managing entity shall have the capability and capacity to submit all the required data electronically into the Substance Abuse and Mental Health Information System (SAMHIS). The contractor shall submit these data based on policies and procedures outlined in the most current version of the pamphlet for. Mental Health and Substance Abuse Measurement and Data – DCF Pamphlet 155-2, effective date September 1, 2008, 9th version (available on the department’s website, www.dcf.state.fl.us/mentalhealth/publications/index.shtml).
(b) The managing entity shall have the capability to ensure that all the data submitted into the SAMHIS database by the contractor or by the network providers under contract with the managing entity not only are complete, accurate, and timely as specified in the Mental Health and Substance Abuse Measurement and Data – DCF Pamphlet 155-2 (available on the department’s website, www.dcf.state.fl.us/mentalhealth/publications/index.shtml) but also are consistent with the data maintained locally by the contractor or by the network providers in their client’s files.
(c) The managing entity shall establish procedures for documenting and reporting service events in such manner as to provide a clear and distinguishable audit trail of each service event submitted into the SAMHIS database. At a minimum, the audit trail documentation shall include the following: the HIPAA procedure code description; service data and duration; the recipient names and identification number; and the staff names and identification number. Such procedures shall ensure that the Department is not billed for unallowable or more service event units than are eligible for payment.
(d) To be paid by the Department, the managing entity shall use the service event data submitted into the SAMHIS database as the main source for verifying and justifying the service units provided by the contractor and the amount billed to or paid by the Department. The Department may deny all or part of the payment if the managing entity fails to comply with this data submission requirement.
(6) Continuous Quality Improvement
(a) The managing entity will establish a clearly delineated continuous improvement program that provides for the meaningful involvement of managing entity personnel, provider organizations, consumers, and stakeholders. The program will:
1. Establish measurable goals and objectives.
2. Develop valid and reliable performance measures and client outcome measures.
3. Measure the overall performance of the managing entity, the system of care, and the performance of participating provider agencies.
4. Measure the managing entities performance in relation to measures established by Federal and state funders.
5. Insure that there are mechanisms that identify performance issues, conduct analysis of performance issues, develop appropriate interventions, and measure the effects of those interventions.
6. Review the results of quality assurance reviews, external monitoring, critical incidents, consumer complaints and grievances, and take steps to initiate improvement.
7. Identify service delivery problems and opportunities for improvement.
8. Measure consumer, community, and provider satisfaction.
(b) The managing entity will establish a Quality Assurance Program that, at a minimum, addresses the following area:
1. Monitor contracted agencies to insure that the managing entity contract requirements are met.
2. Monitor provider invoices for accuracy and allowability of the services billed.
3. Monitor data submitted by contracted providers to insure completeness and accuracy.
4. Establish an Incident Reporting and notification system that provides timely reporting of adverse incidents.
5. The Quality Assurance Program will include specifications for the monitoring of each contractor to insure quality of client services.
(7) Peer Review
(a) The managing entity continuous quality improvement program will include a peer review process that involves the review of staff member’s professional work by comparing trained and qualified individuals who perform similar tasks.
(b) The managing entity will insure that all participating agencies has a peer review process in place.
(c) The managing entity may establish a peer review process that reviews agency clinical practices and provides technical assistance to individuals and agencies in the adoption and use of evidence-based practices.
(8) Utilization Management
(a) The managing entity will develop a utilization management program that at a minimum:
1. Measures the cost effectiveness and appropriateness of treatment services.
2. Establishes agency procedures for the elimination of waiting lists, maximizing the utilization and appropriateness of treatment services.
3. Utilization management practices may include preauthorization of service, retrospective reviews of service utilization, as well as, specialized provider reviews of service utilization.
(9) Technical Assistance and Training
(a) The managing entity will provide technical assistance and training in a minimum of two areas:
1. Provide technical assistance and training to network providers in network functions such as contract management and invoice submission; data reporting and analysis, and quality improvement functions.
2. Provide training and technical assistance in the adoption and implementation of evidence-based practices.
3. The managing entity may either provide training and technical assistance directly or arrange for the provision of technical assistance and training.
(10) Board Development and Governance
(a) The managing entity will provide board development activities:
1. Orient Board members to their respective obligations as Board members.
2. Orient Board members to the activities of the managing entity and its provider agencies.
3. Insure that the Board is fully informed on policies which they will be voting.
Specific Authority 394.9082(10) FS. Law Implemented 394.9082 FS. History–New
65D-31.005 Managing Entity Policies Requiring Departmental Approval.
(1) The managing entity will ensure provider compliance with all applicable Federal and state statues, rules, and Departmental procedures. Managing entities will submit critical policies and procedures to the Department for review and approval. At a minimum, the policies addressing the following will be submitted to the Department for approval:
(a) Contract administration, management, and monitoring.
(b) Standards for client records.
(c) Continuity of care and case management of persons civilly committed to state mental health treatment facilities and for those persons on involuntary outpatient status.
(d) The assessment of service and treatment needs of individuals in state mental health treatment facilities who are ready to return to the community. The procedure will address the identification of services individuals will need upon return to the community, procedures for obtaining identified services and ensuring an array of services is provided to meet individual needs.
(e) Forensic services – continuity of care, case management, community-based competence, restoration, and coordination of conditional release for individuals committed pursuant to Chapter 916, F.S.
(f) A policy that delineates the managing entities activities in monitoring emergency and acute care services and the effective utilization of those services. The policy must also address relationships with public and private receiving facilities, any local transportation plans or protocols required to ensure timely client access to services.
(g) Incident reporting.
(h) Quality assurance – provider monitoring to insure compliance with client care requirements, contacting and financial specifications of statue, rule, and policies and contract requirements.
(i) Data collection, reporting, and analysis.
(j) Provider selection, retention, and provider relation.
(k) Utilization management.
(l) Continuous quality improvement.
(m) Financial management, accountability, and allocation of funds.
(n) Consumer and family involvement and consumer relations.
(o) Cultural competency.
(p) Client rights.
(q) Board member recruitment, activities, and retention.
(r) Disaster planning and response.
Specific Authority 394.9082(10) FS. Law Implemented 394.9082 FS. History–New
65D-31.006 Department’s Responsibilities.
(1) Notwithstanding the Department’s responsibilities as authorized in Chapters 394 and 397, Florida Statutes; upon contracting with a comprehensive managing entity, the Department will:
(a) Conduct on-site readiness reviews of the managing entity to assess its operational capacity and capabilities and determine its ability to satisfactorily perform the duties to be contracted.
(b) The Department in collaboration with community stakeholders, including providers and managing entities will develop objective standards to measure the competence of managing entities to assume the responsibilities described in Chapter 394.9082, F.S.
(c) Monitor the performance of managing entities to ensure compliance with applicable statutes, rules, policies, and contract requirements.
(d) The Department will retain the responsibilities for licensing of Substance Abuse Prevention and Treatment Providers, the designation of both private and public Baker Act receiving facilities, and the designation of Addictions Receiving Facilities.
(e) The Department will negotiate annually with the managing entity to determine performance measures, quality improvement goals, and the quality assurance activities of the managing entity.
(f) The Department will provide guidelines for both the managing entity’s strategic and annual business or operational plan.
1. Plan guidelines will reflect the Department’s strategic goals, objectives, and initiatives established by the Legislature and Department.
2. The Department is responsible for the timely review of the managing entity and for identifying needed amendments or modifications to the plan.
(g) The Department will provide minimum specifications for those managing entity policies requiring departmental approval.
1. The Department is responsible for the timely review of the required policies and for identifying required amendments or modifications necessary to gain departmental approval.
(h) The Department is responsible for providing the specifications to the managing entity for a disaster continuity of operation plan and disaster response requirements.
Specific Authority 394.9082(10) FS. Law Implemented 394.9082 FS. History–New