HB 7067

1	A bill to be entitled
2	An act relating to a model fixed-payment service delivery
3	system for people with developmental disabilities;
4	amending s. 409.912, F.S.; requiring the Agency for Health
5	Care Administration to implement federal waivers to
6	administer a model fixed-payment service delivery system
7	for Medicaid recipients with developmental disabilities;
8	providing legislative intent; providing for implementation
9	of the system on a pilot basis in certain areas of the
10	state; providing for administration of the system by the
11	Agency for Persons with Disabilities; providing
12	requirements for selection of entities to operate the
13	system; providing for mandatory enrollment in system pilot
14	areas; requiring an evaluation of the system; requiring
15	the agency to submit a report to the Governor and
16	Legislature; authorizing the agency to seek certain
17	waivers and adopt rules; requiring the agency to receive
18	specific authorization prior to expanding the system;
19	providing an effective date.
20
21	Be It Enacted by the Legislature of the State of Florida:
22
23	Section 1.  Subsection (53) is added to section 409.912,
24	Florida Statutes, to read:
25	409.912  Cost-effective purchasing of health care.--The
26	agency shall purchase goods and services for Medicaid recipients
27	in the most cost-effective manner consistent with the delivery
28	of quality medical care. To ensure that medical services are
29	effectively utilized, the agency may, in any case, require a
30	confirmation or second physician's opinion of the correct
31	diagnosis for purposes of authorizing future services under the
32	Medicaid program. This section does not restrict access to
33	emergency services or poststabilization care services as defined
34	in 42 C.F.R. part 438.114. Such confirmation or second opinion
35	shall be rendered in a manner approved by the agency. The agency
36	shall maximize the use of prepaid per capita and prepaid
37	aggregate fixed-sum basis services when appropriate and other
38	alternative service delivery and reimbursement methodologies,
39	including competitive bidding pursuant to s. 287.057, designed
40	to facilitate the cost-effective purchase of a case-managed
41	continuum of care. The agency shall also require providers to
42	minimize the exposure of recipients to the need for acute
43	inpatient, custodial, and other institutional care and the
44	inappropriate or unnecessary use of high-cost services. The
45	agency shall contract with a vendor to monitor and evaluate the
46	clinical practice patterns of providers in order to identify
47	trends that are outside the normal practice patterns of a
48	provider's professional peers or the national guidelines of a
49	provider's professional association. The vendor must be able to
50	provide information and counseling to a provider whose practice
51	patterns are outside the norms, in consultation with the agency,
52	to improve patient care and reduce inappropriate utilization.
53	The agency may mandate prior authorization, drug therapy
54	management, or disease management participation for certain
55	populations of Medicaid beneficiaries, certain drug classes, or
56	particular drugs to prevent fraud, abuse, overuse, and possible
57	dangerous drug interactions. The Pharmaceutical and Therapeutics
58	Committee shall make recommendations to the agency on drugs for
59	which prior authorization is required. The agency shall inform
60	the Pharmaceutical and Therapeutics Committee of its decisions
61	regarding drugs subject to prior authorization. The agency is
62	authorized to limit the entities it contracts with or enrolls as
63	Medicaid providers by developing a provider network through
64	provider credentialing. The agency may competitively bid single-
65	source-provider contracts if procurement of goods or services
66	results in demonstrated cost savings to the state without
67	limiting access to care. The agency may limit its network based
68	on the assessment of beneficiary access to care, provider
69	availability, provider quality standards, time and distance
70	standards for access to care, the cultural competence of the
71	provider network, demographic characteristics of Medicaid
72	beneficiaries, practice and provider-to-beneficiary standards,
73	appointment wait times, beneficiary use of services, provider
74	turnover, provider profiling, provider licensure history,
75	previous program integrity investigations and findings, peer
76	review, provider Medicaid policy and billing compliance records,
77	clinical and medical record audits, and other factors. Providers
78	shall not be entitled to enrollment in the Medicaid provider
79	network. The agency shall determine instances in which allowing
80	Medicaid beneficiaries to purchase durable medical equipment and
81	other goods is less expensive to the Medicaid program than long-
82	term rental of the equipment or goods. The agency may establish
83	rules to facilitate purchases in lieu of long-term rentals in
84	order to protect against fraud and abuse in the Medicaid program
85	as defined in s. 409.913. The agency may seek federal waivers
86	necessary to administer these policies.
87	(53)  By December 1, 2007, the Agency for Health Care
88	Administration, in consultation with the Agency for Persons with
89	Disabilities, shall create a model fixed-payment service
90	delivery system for persons with developmental disabilities who
91	receive services under the developmental disabilities waiver
92	program administered by the Agency for Persons with
93	Disabilities. Persons with developmental disabilities who
94	receive services under the family and supported living waiver
95	program or the consumer-directed care plus waiver program
96	administered by the Agency for Persons with Disabilities may
97	also be included in the system if the agency determines that
98	such inclusion is feasible and will improve coordination of care
99	and management of costs. The system must transfer and combine
100	all services funded by Medicaid waiver programs and services
101	funded only by the state, including room and board and supported
102	living payments, for individuals who participate in the system.
103	(a)  The Legislature intends that the system provide
104	recipients in Medicaid waiver programs with a coordinated system
105	of services, increased cost predictability, and a stabilized
106	rate of increase in Medicaid expenditures compared to Medicaid
107	expenditures in the pilot areas specified in paragraph (b) for
108	the 3 years before the system was implemented while ensuring:
109	1.  Consumer choice.
110	2.  Opportunities for consumer-directed services.
111	3.  Access to medically necessary services.
112	4.  Coordination of community-based services.
113	5.  Reductions in the unnecessary use of services.
114	(b)  The agency shall implement the system on a pilot basis
115	in Area 1 of the Agency for Persons with Disabilities and in
116	another area that is determined by the agency, in consultation
117	with the Agency for Persons with Disabilities, to be an
118	appropriate pilot site. After completion of the development
119	phase of the system, attainment of necessary federal approval,
120	procurement of qualified entities, and rate setting, the agency
121	shall delegate administration of the system to the Agency for
122	Persons with Disabilities. The Agency for Persons with
123	Disabilities shall administer contracts with qualified entities
124	and provide quality assurance, monitoring oversight, and other
125	duties necessary for the system. The enrollment of Medicaid
126	waiver recipients in the system in pilot areas shall be
127	mandatory.
128	(c)  The agency shall use a competitive procurement process
129	to select entities to operate the system. Entities eligible to
130	submit bids include community service networks that meet
131	standards of financial solvency, as defined and determined by
132	the agency in consultation with the Agency for Persons with
133	Disabilities and the Office of Insurance Regulation, and that
134	are able to take on financial risk for managed care. The agency
135	shall ensure that bid requirements for entities include, but are
136	not limited to, standards related to:
137	1.  Fiscal solvency.
138	2.  Quality of care.
139	3.  Adequacy of access to provider services.
140	4.  Specific requirements of the Medicaid program designed
141	to meet the needs of the Medicaid recipients.
142	5.  The network's infrastructure capacity to manage
143	financial transactions, recordkeeping, data collection, and
144	other administrative functions.
145	6.  The network's ability to submit any financial,
146	programmatic, or recipient encounter data or other information
147	required by the agency to determine the actual services provided
148	and the cost of administering the plan.
149	(d)  When the agency implements the system in an area of
150	the state, the agency shall endeavor to provide recipients
151	enrolled in the system with a choice of plans from qualified
152	entities. The agency shall ensure that an entity operating a
153	system, in addition to other requirements:
154	1.  Identifies the needs of the recipients using a
155	standardized assessment process approved by the agency.
156	2.  Allows a recipient to select any provider that has a
157	contract with the entity, provided that the service offered by
158	the provider is appropriate to meet the needs of the recipient.
159	3.  Makes a good faith effort to develop contracts with
160	qualified providers currently under contract with the Agency for
161	Persons with Disabilities.
162	4.  Develops and uses a service provider qualification
163	system approved by the agency that describes the quality of care
164	standards that providers of services to persons with
165	developmental disabilities must meet in order to obtain a
166	contract with the plan entity.
167	5.  Excludes, when feasible, chronically poor-performing
168	facilities and providers as determined by the agency.
169	6.  Demonstrates a quality assurance system and a
170	performance improvement system that are satisfactory to the
171	agency.
172	(e)  The agency must ensure that the capitation-rate-
173	setting methodology for the system is actuarially sound and
174	reflects the intent to provide quality care in the least
175	restrictive setting. The agency may choose to limit financial
176	risk for entities operating the system to cover high-cost
177	recipients or to address the catastrophic care needs of
178	recipients enrolled in the system.
179	(f)  The system must provide that if the recipient resides
180	in a noncontracted residential facility licensed under chapter
181	393 or chapter 429 at the time of enrollment in the system, the
182	recipient must be permitted to continue to reside in the
183	noncontracted facility. The system must also provide that, in
184	the absence of a contract between the system provider and the
185	residential facility licensed under chapter 393 or chapter 429,
186	the current Medicaid waiver rates must prevail.
187	(g)  Within 24 months after implementation, the agency
188	shall contract for a comprehensive evaluation of the system. The
189	evaluation must include assessments of cost savings, cost-
190	effectiveness, recipient outcomes, consumer choice, access to
191	services, coordination of care, and quality of care. The
192	evaluation must describe administrative or legal barriers to the
193	implementation and operation of the system and include
194	recommendations regarding statewide expansion of the system. The
195	agency shall submit its evaluation report to the Governor, the
196	President of the Senate, and the Speaker of the House of
197	Representatives no later than June 30, 2010.
198	(h)  The agency may seek federal waivers or Medicaid state
199	plan amendments and adopt rules as necessary to administer the
200	system on a pilot basis. The agency must receive specific
201	authorization from the Legislature prior to expanding beyond the
202	pilot areas designated for the implementation of the system.
203	Section 2.  This act shall take effect July 1, 2007.

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