HB 0577

CS

CHAMBER ACTION

1	The Health & Families Council recommends the following:
2
3	Council/Committee Substitute
4	Remove the entire bill and insert:
5	A bill to be entitled
6	An act relating to Medicaid; amending s. 409.912, F.S.;
7	authorizing the Agency for Health Care Administration to
8	implement a federal waiver to administer an integrated,
9	fixed-payment delivery system for Medicaid recipients;
10	providing applicability; creating s. 409.91212, F.S.;
11	requiring the Agency for Health Care Administration to
12	establish a comprehensive geriatric fall prevention
13	program for certain Medicaid recipients; directing the
14	agency to develop the program as an expansion of a certain
15	pilot project conducted in Miami-Dade County; requiring
16	the agency to evaluate the program and report to the
17	Legislature; requiring a plan and timetable for statewide
18	implementation contingent upon certain findings;
19	specifying a timeframe for implementing a certain form of
20	reimbursement; providing a contingent effective date.
21
22	Be It Enacted by the Legislature of the State of Florida:
23
24	Section 1.  Paragraph (e) of subsection (5) of section
25	409.912, Florida Statutes, is amended, and paragraph (f) is
26	added to that subsection, to read:
27	409.912  Cost-effective purchasing of health care.--The
28	agency shall purchase goods and services for Medicaid recipients
29	in the most cost-effective manner consistent with the delivery
30	of quality medical care. To ensure that medical services are
31	effectively utilized, the agency may, in any case, require a
32	confirmation or second physician's opinion of the correct
33	diagnosis for purposes of authorizing future services under the
34	Medicaid program. This section does not restrict access to
35	emergency services or poststabilization care services as defined
36	in 42 C.F.R. part 438.114. Such confirmation or second opinion
37	shall be rendered in a manner approved by the agency. The agency
38	shall maximize the use of prepaid per capita and prepaid
39	aggregate fixed-sum basis services when appropriate and other
40	alternative service delivery and reimbursement methodologies,
41	including competitive bidding pursuant to s. 287.057, designed
42	to facilitate the cost-effective purchase of a case-managed
43	continuum of care. The agency shall also require providers to
44	minimize the exposure of recipients to the need for acute
45	inpatient, custodial, and other institutional care and the
46	inappropriate or unnecessary use of high-cost services. The
47	agency shall contract with a vendor to monitor and evaluate the
48	clinical practice patterns of providers in order to identify
49	trends that are outside the normal practice patterns of a
50	provider's professional peers or the national guidelines of a
51	provider's professional association. The vendor must be able to
52	provide information and counseling to a provider whose practice
53	patterns are outside the norms, in consultation with the agency,
54	to improve patient care and reduce inappropriate utilization.
55	The agency may mandate prior authorization, drug therapy
56	management, or disease management participation for certain
57	populations of Medicaid beneficiaries, certain drug classes, or
58	particular drugs to prevent fraud, abuse, overuse, and possible
59	dangerous drug interactions. The Pharmaceutical and Therapeutics
60	Committee shall make recommendations to the agency on drugs for
61	which prior authorization is required. The agency shall inform
62	the Pharmaceutical and Therapeutics Committee of its decisions
63	regarding drugs subject to prior authorization. The agency is
64	authorized to limit the entities it contracts with or enrolls as
65	Medicaid providers by developing a provider network through
66	provider credentialing. The agency may competitively bid single-
67	source-provider contracts if procurement of goods or services
68	results in demonstrated cost savings to the state without
69	limiting access to care. The agency may limit its network based
70	on the assessment of beneficiary access to care, provider
71	availability, provider quality standards, time and distance
72	standards for access to care, the cultural competence of the
73	provider network, demographic characteristics of Medicaid
74	beneficiaries, practice and provider-to-beneficiary standards,
75	appointment wait times, beneficiary use of services, provider
76	turnover, provider profiling, provider licensure history,
77	previous program integrity investigations and findings, peer
78	review, provider Medicaid policy and billing compliance records,
79	clinical and medical record audits, and other factors. Providers
80	shall not be entitled to enrollment in the Medicaid provider
81	network. The agency shall determine instances in which allowing
82	Medicaid beneficiaries to purchase durable medical equipment and
83	other goods is less expensive to the Medicaid program than long-
84	term rental of the equipment or goods. The agency may establish
85	rules to facilitate purchases in lieu of long-term rentals in
86	order to protect against fraud and abuse in the Medicaid program
87	as defined in s. 409.913. The agency may seek federal waivers
88	necessary to administer these policies.
89	(5)  By December 1, 2005, the Agency for Health Care
90	Administration, in partnership with the Department of Elderly
91	Affairs, shall create an integrated, fixed-payment delivery
92	system for Medicaid recipients who are 60 years of age or older.
93	The Agency for Health Care Administration shall implement the
94	integrated system initially on a pilot basis in two areas of the
95	state. In one of the areas enrollment shall be on a voluntary
96	basis. The program must transfer all Medicaid services for
97	eligible elderly individuals who choose to participate into an
98	integrated-care management model designed to serve Medicaid
99	recipients in the community. The program must combine all
100	funding for Medicaid services provided to individuals 60 years
101	of age or older into the integrated system, including funds for
102	Medicaid home and community-based waiver services; all Medicaid
103	services authorized in ss. 409.905 and 409.906, excluding funds
104	for Medicaid nursing home services unless the agency is able to
105	demonstrate how the integration of the funds will improve
106	coordinated care for these services in a less costly manner; and
107	Medicare coinsurance and deductibles for persons dually eligible
108	for Medicaid and Medicare as prescribed in s. 409.908(13).
109	(e)  The agency may seek federal waivers and adopt rules as
110	necessary to administer the integrated system and may implement
111	an approved waiver. The agency must receive specific
112	authorization from the Legislature prior to implementing the
113	waiver for the integrated system.
114	(f)  It is the intent of the Legislature that if any
115	conflict exists between the provisions contained in this section
116	and other provisions of this chapter that relate to the
117	implementation of the Medicaid integrated system, the provisions
118	contained in this section shall control.
119	Section 2.  Section 409.91212, Florida Statutes, is created
120	to read:
121	409.91212  Medicaid comprehensive geriatric fall prevention
122	program.--
123	(1)(a)  The Agency for Health Care Administration shall
124	establish a comprehensive geriatric fall prevention program for
125	Medicaid recipients in Miami-Dade County. The program shall be
126	evidence-based and shall expand the geriatric fall prevention
127	demonstration project awarded under contract in 2002 by the
128	Agency for Health Care Administration. The program shall serve
129	up to 7,000 Medicaid recipients during the first year of
130	operation and shall be in operation within 120 days after the
131	effective date of this act.
132	(b)  The agency shall evaluate the cost-effectiveness and
133	clinical effectiveness of the program and report its findings to
134	the President of the Senate and the Speaker of the House of
135	Representatives by January 1, 2009. If the findings indicate the
136	program is cost-effective and clinically effective, the report
137	shall include a plan and timetable for statewide implementation.
138	In evaluating the cost-effectiveness and clinical effectiveness
139	of the program, the agency must consider findings from program
140	evaluations and site visit reports relating to the demonstration
141	project described in paragraph (a).
142	(2)  Services provided under subsection (1) shall be
143	reimbursed on the same basis as provided for under the
144	demonstration project contracts described in subsection (1).
145	Beginning on the first day of operation in the third year of
146	program implementation, as authorized under this section,
147	services shall be reimbursed only on a capitated, risk-adjusted
148	basis.
149	Section 3.  This act shall take effect July 1, 2006;
150	however, section 2 shall take effect only if a specific
151	appropriation to implement the Medicaid comprehensive geriatric
152	fall prevention program as created in s. 409.91212, Florida
153	Statutes, in this act is made in the General Appropriations Act
154	for fiscal year 2006-2007.

CODING: Words stricken are deletions; words underlined are additions.