HB 1319

1	A bill to be entitled
2	An act relating to a Medicaid utilization management
3	program; amending s. 409.912, F.S.; deleting a provision
4	that requires the Agency for Health Care Administration to
5	develop and implement a utilization management program for
6	Medicaid-eligible recipients for the management of
7	occupational, physical, respiratory, and speech therapies;
8	amending s. 409.91211, F.S.; conforming a cross-reference;
9	providing an effective date.
10
11	Be It Enacted by the Legislature of the State of Florida:
12
13	Section 1.  Subsections (43) through (52) of section
14	409.912, Florida Statutes, are renumbered as subsections (42)
15	through (51), respectively, and present subsection (42) of that
16	section is amended to read:
17	409.912  Cost-effective purchasing of health care.--The
18	agency shall purchase goods and services for Medicaid recipients
19	in the most cost-effective manner consistent with the delivery
20	of quality medical care. To ensure that medical services are
21	effectively utilized, the agency may, in any case, require a
22	confirmation or second physician's opinion of the correct
23	diagnosis for purposes of authorizing future services under the
24	Medicaid program. This section does not restrict access to
25	emergency services or poststabilization care services as defined
26	in 42 C.F.R. part 438.114. Such confirmation or second opinion
27	shall be rendered in a manner approved by the agency. The agency
28	shall maximize the use of prepaid per capita and prepaid
29	aggregate fixed-sum basis services when appropriate and other
30	alternative service delivery and reimbursement methodologies,
31	including competitive bidding pursuant to s. 287.057, designed
32	to facilitate the cost-effective purchase of a case-managed
33	continuum of care. The agency shall also require providers to
34	minimize the exposure of recipients to the need for acute
35	inpatient, custodial, and other institutional care and the
36	inappropriate or unnecessary use of high-cost services. The
37	agency shall contract with a vendor to monitor and evaluate the
38	clinical practice patterns of providers in order to identify
39	trends that are outside the normal practice patterns of a
40	provider's professional peers or the national guidelines of a
41	provider's professional association. The vendor must be able to
42	provide information and counseling to a provider whose practice
43	patterns are outside the norms, in consultation with the agency,
44	to improve patient care and reduce inappropriate utilization.
45	The agency may mandate prior authorization, drug therapy
46	management, or disease management participation for certain
47	populations of Medicaid beneficiaries, certain drug classes, or
48	particular drugs to prevent fraud, abuse, overuse, and possible
49	dangerous drug interactions. The Pharmaceutical and Therapeutics
50	Committee shall make recommendations to the agency on drugs for
51	which prior authorization is required. The agency shall inform
52	the Pharmaceutical and Therapeutics Committee of its decisions
53	regarding drugs subject to prior authorization. The agency is
54	authorized to limit the entities it contracts with or enrolls as
55	Medicaid providers by developing a provider network through
56	provider credentialing. The agency may competitively bid single-
57	source-provider contracts if procurement of goods or services
58	results in demonstrated cost savings to the state without
59	limiting access to care. The agency may limit its network based
60	on the assessment of beneficiary access to care, provider
61	availability, provider quality standards, time and distance
62	standards for access to care, the cultural competence of the
63	provider network, demographic characteristics of Medicaid
64	beneficiaries, practice and provider-to-beneficiary standards,
65	appointment wait times, beneficiary use of services, provider
66	turnover, provider profiling, provider licensure history,
67	previous program integrity investigations and findings, peer
68	review, provider Medicaid policy and billing compliance records,
69	clinical and medical record audits, and other factors. Providers
70	shall not be entitled to enrollment in the Medicaid provider
71	network. The agency shall determine instances in which allowing
72	Medicaid beneficiaries to purchase durable medical equipment and
73	other goods is less expensive to the Medicaid program than long-
74	term rental of the equipment or goods. The agency may establish
75	rules to facilitate purchases in lieu of long-term rentals in
76	order to protect against fraud and abuse in the Medicaid program
77	as defined in s. 409.913. The agency may seek federal waivers
78	necessary to administer these policies.
79	(42)  The agency shall develop and implement a utilization
80	management program for Medicaid-eligible recipients for the
81	management of occupational, physical, respiratory, and speech
82	therapies. The agency shall establish a utilization program that
83	may require prior authorization in order to ensure medically
84	necessary and cost-effective treatments. The program shall be
85	operated in accordance with a federally approved waiver program
86	or state plan amendment. The agency may seek a federal waiver or
87	state plan amendment to implement this program. The agency may
88	also competitively procure these services from an outside vendor
89	on a regional or statewide basis.
90	Section 2.  Paragraph (e) of subsection (3) of section
91	409.91211, Florida Statutes, is amended to read:
92	409.91211  Medicaid managed care pilot program.--
93	(3)  The agency shall have the following powers, duties,
94	and responsibilities with respect to the pilot program:
95	(e)  To implement policies and guidelines for phasing in
96	financial risk for approved provider service networks over a 3-
97	year period. These policies and guidelines must include an
98	option for a provider service network to be paid fee-for-service
99	rates. For any provider service network established in a managed
100	care pilot area, the option to be paid fee-for-service rates
101	shall include a savings-settlement mechanism that is consistent
102	with s. 409.912(43)(44). This model shall be converted to a
103	risk-adjusted capitated rate no later than the beginning of the
104	fourth year of operation, and may be converted earlier at the
105	option of the provider service network. Federally qualified
106	health centers may be offered an opportunity to accept or
107	decline a contract to participate in any provider network for
108	prepaid primary care services.
109	Section 3.  This act shall take effect July 1, 2008.

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