HB 943

1	A bill to be entitled
2	An act relating to Medicaid reimbursement rates; amending
3	s. 409.912, F.S.; requiring entities under contract with
4	the Agency for Health Care Administration to reimburse
5	noncontracted hospitals and physicians at certain rates;
6	providing an exception; amending s. 409.915, F.S.;
7	providing for semiannual calculation of Medicaid county
8	participation rates for the purpose of determining a
9	county's contribution to Medicaid for certain hospital
10	services; providing for publication of participation
11	rates; providing an effective date.
12
13	Be It Enacted by the Legislature of the State of Florida:
14
15	Section 1.  Subsection (19) of section 409.912, Florida
16	Statutes, 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	(19)  An entity that contracts with the agency on a prepaid
80	or fixed-sum basis for the provision of Medicaid services shall:
81	(a)  Reimburse any hospital or physician that is outside
82	the entity's authorized geographic service area as specified in
83	its contract with the agency, and that provides services
84	authorized by the entity to its members, at a rate negotiated
85	with the hospital or physician for the provision of services or
86	according to the lesser of the following:
87	1.(a)  The usual and customary charges made to the general
88	public by the hospital or physician; or
89	2.(b)  The Florida Medicaid reimbursement rate established
90	for the hospital or physician.
91	(b)  Reimburse any otherwise noncontracted hospital or
92	physician that is within the entity's authorized geographic
93	service area as specified in its contract with the agency, and
94	that provides services to its members, at the usual or customary
95	charges made to the general public by the hospital or physician.
96
97	This subsection does not apply to emergency services.
98	Section 2.  Subsection (8) is added to section 409.915,
99	Florida Statutes, to read:
100	409.915  County contributions to Medicaid.--Although the
101	state is responsible for the full portion of the state share of
102	the matching funds required for the Medicaid program, in order
103	to acquire a certain portion of these funds, the state shall
104	charge the counties for certain items of care and service as
105	provided in this section.
106	(8)  A county's contribution to Medicaid for hospital
107	services prescribed under this section shall be based on the
108	Medicaid county participation rate, which shall be calculated on
109	a semiannual basis by the agency. Except for the agency's
110	internal calculations used to determine target, ceiling, and
111	exempt rates, as required from time to time, Medicaid county
112	participation rates shall be published only for the purpose of
113	determining the amount of counties' contributions to Medicaid
114	for hospital services.
115	Section 3.  This act shall take effect July 1, 2009.

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