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A bill to be entitled

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An act relating to a Medicaid utilization management

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program; amending s. 409.912, F.S.; deleting a provision

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that requires the Agency for Health Care Administration to

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develop and implement a utilization management program for

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Medicaid-eligible recipients for the management of

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occupational, physical, respiratory, and speech therapies;

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amending s. 409.91211, F.S.; conforming a cross-reference;

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providing an effective date.

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Be It Enacted by the Legislature of the State of Florida:

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     Section 1.  Subsections (43) through (52) of section

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409.912, Florida Statutes, are renumbered as subsections (42)

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through (51), respectively, and present subsection (42) of that

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section is amended to read:

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     409.912  Cost-effective purchasing of health care.--The

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agency shall purchase goods and services for Medicaid recipients

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in the most cost-effective manner consistent with the delivery of

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quality medical care. To ensure that medical services are

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effectively utilized, the agency may, in any case, require a

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confirmation or second physician's opinion of the correct

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diagnosis for purposes of authorizing future services under the

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Medicaid program. This section does not restrict access to

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emergency services or poststabilization care services as defined

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in 42 C.F.R. part 438.114. Such confirmation or second opinion

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shall be rendered in a manner approved by the agency. The agency

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shall maximize the use of prepaid per capita and prepaid

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aggregate fixed-sum basis services when appropriate and other

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alternative service delivery and reimbursement methodologies,

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including competitive bidding pursuant to s. 287.057, designed to

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facilitate the cost-effective purchase of a case-managed

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continuum of care. The agency shall also require providers to

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minimize the exposure of recipients to the need for acute

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inpatient, custodial, and other institutional care and the

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inappropriate or unnecessary use of high-cost services. The

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agency shall contract with a vendor to monitor and evaluate the

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clinical practice patterns of providers in order to identify

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trends that are outside the normal practice patterns of a

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provider's professional peers or the national guidelines of a

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provider's professional association. The vendor must be able to

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provide information and counseling to a provider whose practice

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patterns are outside the norms, in consultation with the agency,

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to improve patient care and reduce inappropriate utilization. The

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agency may mandate prior authorization, drug therapy management,

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or disease management participation for certain populations of

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Medicaid beneficiaries, certain drug classes, or particular drugs

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to prevent fraud, abuse, overuse, and possible dangerous drug

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interactions. The Pharmaceutical and Therapeutics Committee shall

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make recommendations to the agency on drugs for which prior

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authorization is required. The agency shall inform the

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Pharmaceutical and Therapeutics Committee of its decisions

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regarding drugs subject to prior authorization. The agency is

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authorized to limit the entities it contracts with or enrolls as

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Medicaid providers by developing a provider network through

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provider credentialing. The agency may competitively bid single-

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source-provider contracts if procurement of goods or services

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results in demonstrated cost savings to the state without

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limiting access to care. The agency may limit its network based

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on the assessment of beneficiary access to care, provider

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availability, provider quality standards, time and distance

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standards for access to care, the cultural competence of the

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provider network, demographic characteristics of Medicaid

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beneficiaries, practice and provider-to-beneficiary standards,

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appointment wait times, beneficiary use of services, provider

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turnover, provider profiling, provider licensure history,

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previous program integrity investigations and findings, peer

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review, provider Medicaid policy and billing compliance records,

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clinical and medical record audits, and other factors. Providers

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shall not be entitled to enrollment in the Medicaid provider

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network. The agency shall determine instances in which allowing

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Medicaid beneficiaries to purchase durable medical equipment and

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other goods is less expensive to the Medicaid program than long-

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term rental of the equipment or goods. The agency may establish

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rules to facilitate purchases in lieu of long-term rentals in

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order to protect against fraud and abuse in the Medicaid program

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as defined in s. 409.913. The agency may seek federal waivers

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necessary to administer these policies.

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     (42) The agency shall develop and implement a utilization

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management program for Medicaid-eligible recipients for the

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management of occupational, physical, respiratory, and speech

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therapies. The agency shall establish a utilization program that

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may require prior authorization in order to ensure medically

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necessary and cost-effective treatments. The program shall be

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operated in accordance with a federally approved waiver program

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or state plan amendment. The agency may seek a federal waiver or

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state plan amendment to implement this program. The agency may

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also competitively procure these services from an outside vendor

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on a regional or statewide basis.

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     Section 2.  Paragraph (e) of subsection (3) of section

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409.91211, Florida Statutes, is amended to read:

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     409.91211  Medicaid managed care pilot program.--

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     (3)  The agency shall have the following powers, duties, and

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responsibilities with respect to the pilot program:

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     (e)  To implement policies and guidelines for phasing in

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financial risk for approved provider service networks over a 3-

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year period. These policies and guidelines must include an option

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for a provider service network to be paid fee-for-service rates.

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For any provider service network established in a managed care

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pilot area, the option to be paid fee-for-service rates shall

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include a savings-settlement mechanism that is consistent with s.

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409.912(43)(44). This model shall be converted to a risk-adjusted

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capitated rate no later than the beginning of the fourth year of

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operation, and may be converted earlier at the option of the

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provider service network. Federally qualified health centers may

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be offered an opportunity to accept or decline a contract to

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participate in any provider network for prepaid primary care

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services.

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     Section 3.  This act shall take effect July 1, 2008.