Florida Senate - 2009 SB 1876
By Senator Rich
34-01639-09 20091876__
1 A bill to be entitled
2 An act relating to Medicaid; amending s. 409.912,
3 F.S.; requiring an entity that contracts with the
4 Agency for Health Care Administration for Medicaid
5 services to reimburse certain noncontracted hospitals
6 or physicians for services provided to its members;
7 amending s. 409.915, F.S.; requiring that a county's
8 contribution to Medicaid for hospital services be
9 based on the Medicaid rate calculated by the agency;
10 providing that the sole purpose of the Medicaid county
11 rate is to determine the counties' contribution;
12 providing an effective date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Subsection (19) of section 409.912, Florida
17 Statutes, is amended to read:
18 409.912 Cost-effective purchasing of health care.—The
19 agency shall purchase goods and services for Medicaid recipients
20 in the most cost-effective manner consistent with the delivery
21 of quality medical care. To ensure that medical services are
22 effectively utilized, the agency may, in any case, require a
23 confirmation or second physician's opinion of the correct
24 diagnosis for purposes of authorizing future services under the
25 Medicaid program. This section does not restrict access to
26 emergency services or poststabilization care services as defined
27 in 42 C.F.R. part 438.114. Such confirmation or second opinion
28 shall be rendered in a manner approved by the agency. The agency
29 shall maximize the use of prepaid per capita and prepaid
30 aggregate fixed-sum basis services when appropriate and other
31 alternative service delivery and reimbursement methodologies,
32 including competitive bidding pursuant to s. 287.057, designed
33 to facilitate the cost-effective purchase of a case-managed
34 continuum of care. The agency shall also require providers to
35 minimize the exposure of recipients to the need for acute
36 inpatient, custodial, and other institutional care and the
37 inappropriate or unnecessary use of high-cost services. The
38 agency shall contract with a vendor to monitor and evaluate the
39 clinical practice patterns of providers in order to identify
40 trends that are outside the normal practice patterns of a
41 provider's professional peers or the national guidelines of a
42 provider's professional association. The vendor must be able to
43 provide information and counseling to a provider whose practice
44 patterns are outside the norms, in consultation with the agency,
45 to improve patient care and reduce inappropriate utilization.
46 The agency may mandate prior authorization, drug therapy
47 management, or disease management participation for certain
48 populations of Medicaid beneficiaries, certain drug classes, or
49 particular drugs to prevent fraud, abuse, overuse, and possible
50 dangerous drug interactions. The Pharmaceutical and Therapeutics
51 Committee shall make recommendations to the agency on drugs for
52 which prior authorization is required. The agency shall inform
53 the Pharmaceutical and Therapeutics Committee of its decisions
54 regarding drugs subject to prior authorization. The agency is
55 authorized to limit the entities it contracts with or enrolls as
56 Medicaid providers by developing a provider network through
57 provider credentialing. The agency may competitively bid single
58 source-provider contracts if procurement of goods or services
59 results in demonstrated cost savings to the state without
60 limiting access to care. The agency may limit its network based
61 on the assessment of beneficiary access to care, provider
62 availability, provider quality standards, time and distance
63 standards for access to care, the cultural competence of the
64 provider network, demographic characteristics of Medicaid
65 beneficiaries, practice and provider-to-beneficiary standards,
66 appointment wait times, beneficiary use of services, provider
67 turnover, provider profiling, provider licensure history,
68 previous program integrity investigations and findings, peer
69 review, provider Medicaid policy and billing compliance records,
70 clinical and medical record audits, and other factors. Providers
71 shall not be entitled to enrollment in the Medicaid provider
72 network. The agency shall determine instances in which allowing
73 Medicaid beneficiaries to purchase durable medical equipment and
74 other goods is less expensive to the Medicaid program than long
75 term rental of the equipment or goods. The agency may establish
76 rules to facilitate purchases in lieu of long-term rentals in
77 order to protect against fraud and abuse in the Medicaid program
78 as defined in s. 409.913. The agency may seek federal waivers
79 necessary to administer these policies.
80 (19) An entity that contracts with the agency on a prepaid
81 or fixed-sum basis for the provision of Medicaid services shall
82 reimburse any hospital or physician that is outside the entity's
83 authorized geographic service area as specified in its contract
84 with the agency, and that provides services authorized by the
85 entity to its members, at a rate negotiated with the hospital or
86 physician for the provision of services or according to the
87 lesser of the following:
88 (a) The usual and customary charges made to the general
89 public by the hospital or physician; or
90 (b) The Florida Medicaid reimbursement rate established for
91 the hospital or physician.
92 This entity shall reimburse any otherwise noncontracted hospital
93 or physician that is within the entity’s authorized geographic
94 area and that provides services to its members as specified in
95 its contract with the agency at the usual or customary charges
96 made to the general public by the hospital or physician. This
97 subsection does not apply to emergency services.
98 Section 2. Subsection (8) is added to section 409.915,
99 Florida Statutes, to read:
100 409.915 County contributions to Medicaid.—Although the
101 state is responsible for the full portion of the state share of
102 the matching funds required for the Medicaid program, in order
103 to acquire a certain portion of these funds, the state shall
104 charge the counties for certain items of care and service as
105 provided in this section.
106 (8) A county's contribution to Medicaid for hospital
107 services prescribed in this section shall be based on the
108 Medicaid county rate that shall be calculated semiannually by
109 the agency. Except for the agency's internal calculations used
110 to determine target, ceiling, and exempt rates, as periodically
111 required, the sole purpose of the Medicaid county rate is to
112 determine the counties' contribution, and Medicaid county rates
113 shall be published for that purpose only.
114 Section 3. This act shall take effect July 1, 2009.