| 1 | Representative Zapata offered the following: |
| 2 |
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| 3 | Amendment to Senate Amendment (780200) (with title |
| 4 | amendment) |
| 5 | Between lines 1543 and 1544, insert: |
| 6 | Section 32. Subsection (17) of section 409.912, Florida |
| 7 | Statutes, is amended to read: |
| 8 | 409.912 Cost-effective purchasing of health care.--The |
| 9 | agency shall purchase goods and services for Medicaid recipients |
| 10 | in the most cost-effective manner consistent with the delivery |
| 11 | of quality medical care. To ensure that medical services are |
| 12 | effectively utilized, the agency may, in any case, require a |
| 13 | confirmation or second physician's opinion of the correct |
| 14 | diagnosis for purposes of authorizing future services under the |
| 15 | Medicaid program. This section does not restrict access to |
| 16 | emergency services or poststabilization care services as defined |
| 17 | in 42 C.F.R. part 438.114. Such confirmation or second opinion |
| 18 | shall be rendered in a manner approved by the agency. The agency |
| 19 | shall maximize the use of prepaid per capita and prepaid |
| 20 | aggregate fixed-sum basis services when appropriate and other |
| 21 | alternative service delivery and reimbursement methodologies, |
| 22 | including competitive bidding pursuant to s. 287.057, designed |
| 23 | to facilitate the cost-effective purchase of a case-managed |
| 24 | continuum of care. The agency shall also require providers to |
| 25 | minimize the exposure of recipients to the need for acute |
| 26 | inpatient, custodial, and other institutional care and the |
| 27 | inappropriate or unnecessary use of high-cost services. The |
| 28 | agency shall contract with a vendor to monitor and evaluate the |
| 29 | clinical practice patterns of providers in order to identify |
| 30 | trends that are outside the normal practice patterns of a |
| 31 | provider's professional peers or the national guidelines of a |
| 32 | provider's professional association. The vendor must be able to |
| 33 | provide information and counseling to a provider whose practice |
| 34 | patterns are outside the norms, in consultation with the agency, |
| 35 | to improve patient care and reduce inappropriate utilization. |
| 36 | The agency may mandate prior authorization, drug therapy |
| 37 | management, or disease management participation for certain |
| 38 | populations of Medicaid beneficiaries, certain drug classes, or |
| 39 | particular drugs to prevent fraud, abuse, overuse, and possible |
| 40 | dangerous drug interactions. The Pharmaceutical and Therapeutics |
| 41 | Committee shall make recommendations to the agency on drugs for |
| 42 | which prior authorization is required. The agency shall inform |
| 43 | the Pharmaceutical and Therapeutics Committee of its decisions |
| 44 | regarding drugs subject to prior authorization. The agency is |
| 45 | authorized to limit the entities it contracts with or enrolls as |
| 46 | Medicaid providers by developing a provider network through |
| 47 | provider credentialing. The agency may competitively bid single- |
| 48 | source-provider contracts if procurement of goods or services |
| 49 | results in demonstrated cost savings to the state without |
| 50 | limiting access to care. The agency may limit its network based |
| 51 | on the assessment of beneficiary access to care, provider |
| 52 | availability, provider quality standards, time and distance |
| 53 | standards for access to care, the cultural competence of the |
| 54 | provider network, demographic characteristics of Medicaid |
| 55 | beneficiaries, practice and provider-to-beneficiary standards, |
| 56 | appointment wait times, beneficiary use of services, provider |
| 57 | turnover, provider profiling, provider licensure history, |
| 58 | previous program integrity investigations and findings, peer |
| 59 | review, provider Medicaid policy and billing compliance records, |
| 60 | clinical and medical record audits, and other factors. Providers |
| 61 | shall not be entitled to enrollment in the Medicaid provider |
| 62 | network. The agency shall determine instances in which allowing |
| 63 | Medicaid beneficiaries to purchase durable medical equipment and |
| 64 | other goods is less expensive to the Medicaid program than long- |
| 65 | term rental of the equipment or goods. The agency may establish |
| 66 | rules to facilitate purchases in lieu of long-term rentals in |
| 67 | order to protect against fraud and abuse in the Medicaid program |
| 68 | as defined in s. 409.913. The agency may seek federal waivers |
| 69 | necessary to administer these policies. |
| 70 | (17) An entity contracting on a prepaid or fixed-sum basis |
| 71 | shall, in addition to meeting any applicable statutory surplus |
| 72 | requirements, also maintain at all times in the form of cash, |
| 73 | investments that mature in less than 180 days allowable as |
| 74 | admitted assets by the Office of Insurance Regulation, and |
| 75 | restricted funds or deposits controlled by the agency or the |
| 76 | Office of Insurance Regulation, a surplus amount equal to one- |
| 77 | and-one-half times the entity's monthly Medicaid prepaid |
| 78 | revenues. As used in this subsection, the term "surplus" means |
| 79 | the entity's total assets minus total liabilities. If an |
| 80 | entity's surplus falls below an amount equal to one-and-one-half |
| 81 | times the entity's monthly Medicaid prepaid revenues, the agency |
| 82 | shall prohibit the entity from engaging in marketing and |
| 83 | preenrollment activities, shall cease to process new |
| 84 | enrollments, and shall not renew the entity's contract until the |
| 85 | required balance is achieved. The requirements of this |
| 86 | subsection do not apply: |
| 87 | (a) Where a public entity agrees to fund any deficit |
| 88 | incurred by the contracting entity; or |
| 89 | (b) Where the entity's performance and obligations are |
| 90 | guaranteed in writing by a guaranteeing organization which: |
| 91 | 1. Has been in operation for at least 5 years and has |
| 92 | assets in excess of $50 million; or |
| 93 | 2. Submits a written guarantee acceptable to the agency |
| 94 | which is irrevocable during the term of the contracting entity's |
| 95 | contract with the agency and, upon termination of the contract, |
| 96 | until the agency receives proof of satisfaction of all |
| 97 | outstanding obligations incurred under the contract; or |
| 98 | (c) Where the entity is majority owned or controlled by |
| 99 | one or more of the following: |
| 100 | 1. A federally qualified health center; |
| 101 | 2. A federally qualified health center controlled network; |
| 102 | or |
| 103 | 3. Any not-for-profit entity which is itself majority |
| 104 | owned or controlled by one or more federally qualified health |
| 105 | centers or a federally qualified health center controlled |
| 106 | network and where such entity meets the surplus and reserve |
| 107 | requirements of s.641.225. For purposes of this section, the |
| 108 | terms "federally qualified health center," and "federally |
| 109 | qualified health center controlled network" shall have the |
| 110 | meanings ascribed to them by the United States Department of |
| 111 | Health and Human Services, Health Resources and Services |
| 112 | Administration. |
| 113 |
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| 114 |
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| 115 | ----------------------------------------------------- |
| 116 | T I T L E A M E N D M E N T |
| 117 | Between lines 2077 and 2078, insert: |
| 118 | amending s. 409.912, F.S.; providing additional exceptions to |
| 119 | requirements for certain entities contracting on a prepaid or |
| 120 | fixed-sum basis; |