| 1 | The Elder & Long-Term Care Committee recommends the following: |
| 2 |
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| 3 | Council/Committee Substitute |
| 4 | Remove the entire bill and insert: |
| 5 | A bill to be entitled |
| 6 | An act relating to developmental disabilities; amending s. |
| 7 | 409.912, F.S.; requiring the Agency for Health Care |
| 8 | Administration to develop a model waiver program to serve |
| 9 | children with specified disorders; requiring the agency to |
| 10 | seek federal waiver approval and implement the approved |
| 11 | waiver subject to availability of funds and certain |
| 12 | limitations; authorizing rules; providing an effective |
| 13 | date. |
| 14 |
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| 15 | Be It Enacted by the Legislature of the State of Florida: |
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| 17 | Section 1. Subsection (50) is added to section 409.912, |
| 18 | Florida Statutes, to read: |
| 19 | 409.912 Cost-effective purchasing of health care.--The |
| 20 | agency shall purchase goods and services for Medicaid recipients |
| 21 | in the most cost-effective manner consistent with the delivery |
| 22 | of quality medical care. To ensure that medical services are |
| 23 | effectively utilized, the agency may, in any case, require a |
| 24 | confirmation or second physician's opinion of the correct |
| 25 | diagnosis for purposes of authorizing future services under the |
| 26 | Medicaid program. This section does not restrict access to |
| 27 | emergency services or poststabilization care services as defined |
| 28 | in 42 C.F.R. part 438.114. Such confirmation or second opinion |
| 29 | shall be rendered in a manner approved by the agency. The agency |
| 30 | shall maximize the use of prepaid per capita and prepaid |
| 31 | aggregate fixed-sum basis services when appropriate and other |
| 32 | alternative service delivery and reimbursement methodologies, |
| 33 | including competitive bidding pursuant to s. 287.057, designed |
| 34 | to facilitate the cost-effective purchase of a case-managed |
| 35 | continuum of care. The agency shall also require providers to |
| 36 | minimize the exposure of recipients to the need for acute |
| 37 | inpatient, custodial, and other institutional care and the |
| 38 | inappropriate or unnecessary use of high-cost services. The |
| 39 | agency may mandate prior authorization, drug therapy management, |
| 40 | or disease management participation for certain populations of |
| 41 | Medicaid beneficiaries, certain drug classes, or particular |
| 42 | drugs to prevent fraud, abuse, overuse, and possible dangerous |
| 43 | drug interactions. The Pharmaceutical and Therapeutics Committee |
| 44 | shall make recommendations to the agency on drugs for which |
| 45 | prior authorization is required. The agency shall inform the |
| 46 | Pharmaceutical and Therapeutics Committee of its decisions |
| 47 | regarding drugs subject to prior authorization. The agency is |
| 48 | authorized to limit the entities it contracts with or enrolls as |
| 49 | Medicaid providers by developing a provider network through |
| 50 | provider credentialing. The agency may limit its network based |
| 51 | on the assessment of beneficiary access to care, provider |
| 52 | availability, provider quality standards, time and distance |
| 53 | standards for access to care, the cultural competence of the |
| 54 | provider network, demographic characteristics of Medicaid |
| 55 | beneficiaries, practice and provider-to-beneficiary standards, |
| 56 | appointment wait times, beneficiary use of services, provider |
| 57 | turnover, provider profiling, provider licensure history, |
| 58 | previous program integrity investigations and findings, peer |
| 59 | review, provider Medicaid policy and billing compliance records, |
| 60 | clinical and medical record audits, and other factors. Providers |
| 61 | shall not be entitled to enrollment in the Medicaid provider |
| 62 | network. The agency is authorized to seek federal waivers |
| 63 | necessary to implement this policy. |
| 64 | (50) The agency shall develop a model home and community- |
| 65 | based waiver to serve children who are diagnosed with familial |
| 66 | dysautonomia or Riley-Day syndrome caused by a mutation of the |
| 67 | IKBKAP gene on chromosome 9. The agency shall seek federal |
| 68 | waiver approval and implement the approved waiver subject to the |
| 69 | availability of funds and any limitations provided in the |
| 70 | General Appropriations Act. The agency may adopt rules to |
| 71 | implement this waiver program. |
| 72 | Section 2. This act shall take effect July 1, 2005. |