HB 431

1	A bill to be entitled
2	An act relating to Medicaid coverage for myotubular
3	myopathy; amending s. 409.912, F.S.; requiring the Agency
4	for Health Care Administration to develop a home and
5	community-based services waiver to provide services to
6	persons diagnosed as having myotubular myopathy; requiring
7	the agency to seek approval for the federal waiver and to
8	implement the waiver under certain conditions; authorizing
9	the agency to adopt rules; providing an effective date.
10
11	Be It Enacted by the Legislature of the State of Florida:
12
13	Section 1.  Subsection (54) is added to section 409.912,
14	Florida Statutes, to read:
15	409.912  Cost-effective purchasing of health care.--The
16	agency shall purchase goods and services for Medicaid recipients
17	in the most cost-effective manner consistent with the delivery
18	of quality medical care. To ensure that medical services are
19	effectively utilized, the agency may, in any case, require a
20	confirmation or second physician's opinion of the correct
21	diagnosis for purposes of authorizing future services under the
22	Medicaid program. This section does not restrict access to
23	emergency services or poststabilization care services as defined
24	in 42 C.F.R. part 438.114. Such confirmation or second opinion
25	shall be rendered in a manner approved by the agency. The agency
26	shall maximize the use of prepaid per capita and prepaid
27	aggregate fixed-sum basis services when appropriate and other
28	alternative service delivery and reimbursement methodologies,
29	including competitive bidding pursuant to s. 287.057, designed
30	to facilitate the cost-effective purchase of a case-managed
31	continuum of care. The agency shall also require providers to
32	minimize the exposure of recipients to the need for acute
33	inpatient, custodial, and other institutional care and the
34	inappropriate or unnecessary use of high-cost services. The
35	agency shall contract with a vendor to monitor and evaluate the
36	clinical practice patterns of providers in order to identify
37	trends that are outside the normal practice patterns of a
38	provider's professional peers or the national guidelines of a
39	provider's professional association. The vendor must be able to
40	provide information and counseling to a provider whose practice
41	patterns are outside the norms, in consultation with the agency,
42	to improve patient care and reduce inappropriate utilization.
43	The agency may mandate prior authorization, drug therapy
44	management, or disease management participation for certain
45	populations of Medicaid beneficiaries, certain drug classes, or
46	particular drugs to prevent fraud, abuse, overuse, and possible
47	dangerous drug interactions. The Pharmaceutical and Therapeutics
48	Committee shall make recommendations to the agency on drugs for
49	which prior authorization is required. The agency shall inform
50	the Pharmaceutical and Therapeutics Committee of its decisions
51	regarding drugs subject to prior authorization. The agency is
52	authorized to limit the entities it contracts with or enrolls as
53	Medicaid providers by developing a provider network through
54	provider credentialing. The agency may competitively bid single-
55	source-provider contracts if procurement of goods or services
56	results in demonstrated cost savings to the state without
57	limiting access to care. The agency may limit its network based
58	on the assessment of beneficiary access to care, provider
59	availability, provider quality standards, time and distance
60	standards for access to care, the cultural competence of the
61	provider network, demographic characteristics of Medicaid
62	beneficiaries, practice and provider-to-beneficiary standards,
63	appointment wait times, beneficiary use of services, provider
64	turnover, provider profiling, provider licensure history,
65	previous program integrity investigations and findings, peer
66	review, provider Medicaid policy and billing compliance records,
67	clinical and medical record audits, and other factors. Providers
68	shall not be entitled to enrollment in the Medicaid provider
69	network. The agency shall determine instances in which allowing
70	Medicaid beneficiaries to purchase durable medical equipment and
71	other goods is less expensive to the Medicaid program than long-
72	term rental of the equipment or goods. The agency may establish
73	rules to facilitate purchases in lieu of long-term rentals in
74	order to protect against fraud and abuse in the Medicaid program
75	as defined in s. 409.913. The agency may seek federal waivers
76	necessary to administer these policies.
77	(54)  The agency shall develop a model home and community-
78	based services waiver to provide services for children and
79	adults diagnosed as having myotubular myopathy, a rare,
80	congenital, muscle-wasting disorder characterized by profound
81	loss of muscle tone, weakness of skeletal muscles, respiratory
82	insufficiency, and eye-muscle weakness. The agency shall seek
83	approval for a federal waiver and implement the approved waiver
84	subject to the availability of funds and any limitations
85	provided in the General Appropriations Act. The agency may adopt
86	rules to administer this waiver program.
87	Section 2.  This act shall take effect upon becoming a law.

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