Florida Senate - 2007 COMMITTEE AMENDMENT
Bill No. SB 1828
Barcode 733294
CHAMBER ACTION
Senate House
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04/24/2007 02:22 PM .
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11 The Committee on Health and Human Services Appropriations
12 (Gaetz) recommended the following amendment to amendment
13 (210298):
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15 Senate Amendment (with title amendment)
16 On page 1, between lines 17 and 18,
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18 insert:
19 Section 1. Subsection (44) of section 409.912, Florida
20 Statutes, is amended to read:
21 409.912 Cost-effective purchasing of health care.--The
22 agency shall purchase goods and services for Medicaid
23 recipients in the most cost-effective manner consistent with
24 the delivery of quality medical care. To ensure that medical
25 services are effectively utilized, the agency may, in any
26 case, require a confirmation or second physician's opinion of
27 the correct diagnosis for purposes of authorizing future
28 services under the Medicaid program. This section does not
29 restrict access to emergency services or poststabilization
30 care services as defined in 42 C.F.R. part 438.114. Such
31 confirmation or second opinion shall be rendered in a manner
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Florida Senate - 2007 COMMITTEE AMENDMENT
Bill No. SB 1828
Barcode 733294
1 approved by the agency. The agency shall maximize the use of
2 prepaid per capita and prepaid aggregate fixed-sum basis
3 services when appropriate and other alternative service
4 delivery and reimbursement methodologies, including
5 competitive bidding pursuant to s. 287.057, designed to
6 facilitate the cost-effective purchase of a case-managed
7 continuum of care. The agency shall also require providers to
8 minimize the exposure of recipients to the need for acute
9 inpatient, custodial, and other institutional care and the
10 inappropriate or unnecessary use of high-cost services. The
11 agency shall contract with a vendor to monitor and evaluate
12 the clinical practice patterns of providers in order to
13 identify trends that are outside the normal practice patterns
14 of a provider's professional peers or the national guidelines
15 of a provider's professional association. The vendor must be
16 able to provide information and counseling to a provider whose
17 practice patterns are outside the norms, in consultation with
18 the agency, to improve patient care and reduce inappropriate
19 utilization. The agency may mandate prior authorization, drug
20 therapy management, or disease management participation for
21 certain populations of Medicaid beneficiaries, certain drug
22 classes, or particular drugs to prevent fraud, abuse, overuse,
23 and possible dangerous drug interactions. The Pharmaceutical
24 and Therapeutics Committee shall make recommendations to the
25 agency on drugs for which prior authorization is required. The
26 agency shall inform the Pharmaceutical and Therapeutics
27 Committee of its decisions regarding drugs subject to prior
28 authorization. The agency is authorized to limit the entities
29 it contracts with or enrolls as Medicaid providers by
30 developing a provider network through provider credentialing.
31 The agency may competitively bid single-source-provider
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Florida Senate - 2007 COMMITTEE AMENDMENT
Bill No. SB 1828
Barcode 733294
1 contracts if procurement of goods or services results in
2 demonstrated cost savings to the state without limiting access
3 to care. The agency may limit its network based on the
4 assessment of beneficiary access to care, provider
5 availability, provider quality standards, time and distance
6 standards for access to care, the cultural competence of the
7 provider network, demographic characteristics of Medicaid
8 beneficiaries, practice and provider-to-beneficiary standards,
9 appointment wait times, beneficiary use of services, provider
10 turnover, provider profiling, provider licensure history,
11 previous program integrity investigations and findings, peer
12 review, provider Medicaid policy and billing compliance
13 records, clinical and medical record audits, and other
14 factors. Providers shall not be entitled to enrollment in the
15 Medicaid provider network. The agency shall determine
16 instances in which allowing Medicaid beneficiaries to purchase
17 durable medical equipment and other goods is less expensive to
18 the Medicaid program than long-term rental of the equipment or
19 goods. The agency may establish rules to facilitate purchases
20 in lieu of long-term rentals in order to protect against fraud
21 and abuse in the Medicaid program as defined in s. 409.913.
22 The agency may seek federal waivers necessary to administer
23 these policies.
24 (44) The Agency for Health Care Administration shall
25 ensure that any Medicaid managed care plan as defined in s.
26 409.9122(2)(f), whether paid on a capitated basis or a shared
27 savings basis, is cost-effective. For purposes of this
28 subsection, the term "cost-effective" means that a network's
29 per-member, per-month costs to the state, including, but not
30 limited to, fee-for-service costs, administrative costs, and
31 case-management fees, if any, must be no greater than the
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Florida Senate - 2007 COMMITTEE AMENDMENT
Bill No. SB 1828
Barcode 733294
1 state's costs associated with contracts for Medicaid services
2 established under subsection (3), which may be adjusted for
3 health status. Settlements paid on a shared savings basis
4 shall be calculated using the fully risk-adjusted rate for
5 individual enrollees based on full Medicaid costs under
6 fee-for-service rates applicable during the 2005-2006 fiscal
7 year and each subsequent budget year. The risk corridors
8 established for plans under subsection (3) and any discount
9 factors used in calculated HMO rates do not apply to provider
10 service networks and other plans defined under paragraph
11 (4)(d). The agency shall conduct actuarially sound adjustments
12 for health status in order to ensure such cost-effectiveness
13 and shall publish the results on its Internet website and
14 submit the results annually to the Governor, the President of
15 the Senate, and the Speaker of the House of Representatives no
16 later than December 31 of each year. Contracts established
17 pursuant to this subsection which are not cost-effective may
18 not be renewed.
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20 (Redesignate subsequent sections.)
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23 ================ T I T L E A M E N D M E N T ===============
24 And the title is amended as follows:
25 On page 4, line 26, after the first semicolon,
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27 insert:
28 amending s. 409.912, F.S.; directing that cost
29 shared savings settlements be calculated using
30 the fully risk-adjusted rate for individual
31 enrollees based on full Medicaid costs under
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Florida Senate - 2007 COMMITTEE AMENDMENT
Bill No. SB 1828
Barcode 733294
1 fee-for-service applicable during a specified
2 fiscal year;
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