Senate Bill sb2450
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Florida Senate - 2007 SB 2450
By Senator Peaden
2-1705A-07
1 A bill to be entitled
2 An act relating to health care; amending s.
3 409.912, F.S.; authorizing the Agency for
4 Health Care Administration to implement an
5 integrated, fixed-payment delivery system for
6 certain Medicaid recipients; providing that
7 enrollment in areas within which a pilot
8 program is conducted is voluntary; authorizing
9 the agency to implement federal waivers without
10 prior authorization from the Legislature;
11 providing an effective date.
12
13 Be It Enacted by the Legislature of the State of Florida:
14
15 Section 1. Subsection (5) of section 409.912, Florida
16 Statutes, is amended to read:
17 409.912 Cost-effective purchasing of health care.--The
18 agency shall purchase goods and services for Medicaid
19 recipients in the most cost-effective manner consistent with
20 the delivery of quality medical care. To ensure that medical
21 services are effectively utilized, the agency may, in any
22 case, require a confirmation or second physician's opinion of
23 the correct diagnosis for purposes of authorizing future
24 services under the Medicaid program. This section does not
25 restrict access to emergency services or poststabilization
26 care services as defined in 42 C.F.R. part 438.114. Such
27 confirmation or second opinion shall be rendered in a manner
28 approved by the agency. The agency shall maximize the use of
29 prepaid per capita and prepaid aggregate fixed-sum basis
30 services when appropriate and other alternative service
31 delivery and reimbursement methodologies, including
1
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Florida Senate - 2007 SB 2450
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1 competitive bidding pursuant to s. 287.057, designed to
2 facilitate the cost-effective purchase of a case-managed
3 continuum of care. The agency shall also require providers to
4 minimize the exposure of recipients to the need for acute
5 inpatient, custodial, and other institutional care and the
6 inappropriate or unnecessary use of high-cost services. The
7 agency shall contract with a vendor to monitor and evaluate
8 the clinical practice patterns of providers in order to
9 identify trends that are outside the normal practice patterns
10 of a provider's professional peers or the national guidelines
11 of a provider's professional association. The vendor must be
12 able to provide information and counseling to a provider whose
13 practice patterns are outside the norms, in consultation with
14 the agency, to improve patient care and reduce inappropriate
15 utilization. The agency may mandate prior authorization, drug
16 therapy management, or disease management participation for
17 certain populations of Medicaid beneficiaries, certain drug
18 classes, or particular drugs to prevent fraud, abuse, overuse,
19 and possible dangerous drug interactions. The Pharmaceutical
20 and Therapeutics Committee shall make recommendations to the
21 agency on drugs for which prior authorization is required. The
22 agency shall inform the Pharmaceutical and Therapeutics
23 Committee of its decisions regarding drugs subject to prior
24 authorization. The agency is authorized to limit the entities
25 it contracts with or enrolls as Medicaid providers by
26 developing a provider network through provider credentialing.
27 The agency may competitively bid single-source-provider
28 contracts if procurement of goods or services results in
29 demonstrated cost savings to the state without limiting access
30 to care. The agency may limit its network based on the
31 assessment of beneficiary access to care, provider
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Florida Senate - 2007 SB 2450
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1 availability, provider quality standards, time and distance
2 standards for access to care, the cultural competence of the
3 provider network, demographic characteristics of Medicaid
4 beneficiaries, practice and provider-to-beneficiary standards,
5 appointment wait times, beneficiary use of services, provider
6 turnover, provider profiling, provider licensure history,
7 previous program integrity investigations and findings, peer
8 review, provider Medicaid policy and billing compliance
9 records, clinical and medical record audits, and other
10 factors. Providers shall not be entitled to enrollment in the
11 Medicaid provider network. The agency shall determine
12 instances in which allowing Medicaid beneficiaries to purchase
13 durable medical equipment and other goods is less expensive to
14 the Medicaid program than long-term rental of the equipment or
15 goods. The agency may establish rules to facilitate purchases
16 in lieu of long-term rentals in order to protect against fraud
17 and abuse in the Medicaid program as defined in s. 409.913.
18 The agency may seek federal waivers necessary to administer
19 these policies.
20 (5) By December 1, 2005, the Agency for Health Care
21 Administration, in partnership with the Department of Elderly
22 Affairs, shall create an integrated, fixed-payment delivery
23 system for Medicaid recipients who are 60 years of age or
24 older. The Agency for Health Care Administration shall
25 implement the integrated system initially on a pilot basis in
26 two areas of the state. In one of the areas Enrollment in the
27 pilot areas shall be on a voluntary basis. The program must
28 transfer all Medicaid services for eligible elderly
29 individuals who choose to participate into an integrated-care
30 management model designed to serve Medicaid recipients in the
31 community. The program must combine all funding for Medicaid
3
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Florida Senate - 2007 SB 2450
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1 services provided to individuals 60 years of age or older into
2 the integrated system, including funds for Medicaid home and
3 community-based waiver services; all Medicaid services
4 authorized in ss. 409.905 and 409.906, excluding funds for
5 Medicaid nursing home services unless the agency is able to
6 demonstrate how the integration of the funds will improve
7 coordinated care for these services in a less costly manner;
8 and Medicare coinsurance and deductibles for persons dually
9 eligible for Medicaid and Medicare as prescribed in s.
10 409.908(13).
11 (a) Individuals who are 60 years of age or older and
12 enrolled in the developmental disabilities waiver program, the
13 family and supported-living waiver program, the project AIDS
14 care waiver program, the traumatic brain injury and spinal
15 cord injury waiver program, the consumer-directed care waiver
16 program, and the program of all-inclusive care for the elderly
17 program, and residents of institutional care facilities for
18 the developmentally disabled, must be excluded from the
19 integrated system.
20 (b) The program must use a competitive procurement
21 process to select entities to operate the integrated system.
22 Entities eligible to submit bids include managed care
23 organizations licensed under chapter 641, including entities
24 eligible to participate in the nursing home diversion program,
25 other qualified providers as defined in s. 430.703(7),
26 community care for the elderly lead agencies, and other
27 state-certified community service networks that meet
28 comparable standards as defined by the agency, in consultation
29 with the Department of Elderly Affairs and the Office of
30 Insurance Regulation, to be financially solvent and able to
31 take on financial risk for managed care. Community service
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Florida Senate - 2007 SB 2450
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1 networks that are certified pursuant to the comparable
2 standards defined by the agency are not required to be
3 licensed under chapter 641.
4 (c) The agency must ensure that the
5 capitation-rate-setting methodology for the integrated system
6 is actuarially sound and reflects the intent to provide
7 quality care in the least restrictive setting. The agency must
8 also require integrated-system providers to develop a
9 credentialing system for service providers and to contract
10 with all Gold Seal nursing homes, where feasible, and exclude,
11 where feasible, chronically poor-performing facilities and
12 providers as defined by the agency. The integrated system must
13 provide that if the recipient resides in a noncontracted
14 residential facility licensed under chapter 400 or chapter 429
15 at the time the integrated system is initiated, the recipient
16 must be permitted to continue to reside in the noncontracted
17 facility as long as the recipient desires. The integrated
18 system must also provide that, in the absence of a contract
19 between the integrated-system provider and the residential
20 facility licensed under chapter 400 or chapter 429, current
21 Medicaid rates must prevail. The agency and the Department of
22 Elderly Affairs must jointly develop procedures to manage the
23 services provided through the integrated system in order to
24 ensure quality and recipient choice.
25 (d) Within 24 months after implementation, the Office
26 of Program Policy Analysis and Government Accountability, in
27 consultation with the Auditor General, shall comprehensively
28 evaluate the pilot project for the integrated, fixed-payment
29 delivery system for Medicaid recipients who are 60 years of
30 age or older. The evaluation must include assessments of cost
31 savings; consumer education, choice, and access to services;
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Florida Senate - 2007 SB 2450
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1 coordination of care; and quality of care. The evaluation must
2 describe administrative or legal barriers to the
3 implementation and operation of the pilot program and include
4 recommendations regarding statewide expansion of the pilot
5 program. The office shall submit an evaluation report to the
6 Governor, the President of the Senate, and the Speaker of the
7 House of Representatives no later than June 30, 2008.
8 (e) The agency may seek federal waivers and adopt
9 rules as necessary to administer the integrated system. The
10 agency may implement the approved federal waivers and other
11 provisions as specified in this section. The agency must
12 receive specific authorization from the Legislature prior to
13 implementing the waiver for the integrated system.
14 Section 2. This act shall take effect upon becoming a
15 law.
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18 SENATE SUMMARY
19 Authorizes the Agency for Health Care Administration to
implement an integrated, fixed-payment delivery system
20 for certain Medicaid recipients. Provides that enrollment
in certain pilot areas is voluntary. Authorizes the
21 agency to implement federal waivers without authorization
from the Legislature.
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