CS/HB 1125

1	A bill to be entitled
2	An act relating to health and human services; amending s.
3	408.910, F.S.; providing and revising definitions;
4	revising eligibility requirements for participation in the
5	Florida Health Choices Program; providing that statutory
6	rural hospitals are eligible as employers rather than
7	participants under the program; permitting specified
8	eligible vendors to sell health maintenance contracts or
9	products and services; requiring certain risk-bearing
10	products offered by insurers to be approved by the Office
11	of Insurance Regulation; providing requirements for
12	product certification; providing duties of the Florida
13	Health Choices, Inc., including maintenance of a toll-free
14	telephone hotline to respond to requests for assistance;
15	providing for enrollment periods; providing for certain
16	risk pooling data used by the corporation to be reported
17	annually; amending s. 409.821, F.S.; authorizing personal
18	identifying information of a Florida Kidcare program
19	applicant to be disclosed to the Florida Health Choices,
20	Inc., to administer the program; amending s. 409.912,
21	F.S.; requiring the Agency for Health Care Administration
22	to establish a demonstration project in Miami-Dade County
23	of a long-term-care facility and a psychiatric facility to
24	improve access to health care by medically underserved
25	persons; providing an effective date.
26
27	Be It Enacted by the Legislature of the State of Florida:
28
29	Section 1.  Section 408.910, Florida Statutes, is amended
30	to read:
31	408.910  Florida Health Choices Program.-
32	(1)  LEGISLATIVE INTENT.-The Legislature finds that a
33	significant number of the residents of this state do not have
34	adequate access to affordable, quality health care. The
35	Legislature further finds that increasing access to affordable,
36	quality health care can be best accomplished by establishing a
37	competitive market for purchasing health insurance and health
38	services. It is therefore the intent of the Legislature to
39	create the Florida Health Choices Program to:
40	(a)  Expand opportunities for Floridians to purchase
41	affordable health insurance and health services.
42	(b)  Preserve the benefits of employment-sponsored
43	insurance while easing the administrative burden for employers
44	who offer these benefits.
45	(c)  Enable individual choice in both the manner and amount
46	of health care purchased.
47	(d)  Provide for the purchase of individual, portable
48	health care coverage.
49	(e)  Disseminate information to consumers on the price and
50	quality of health services.
51	(f)  Sponsor a competitive market that stimulates product
52	innovation, quality improvement, and efficiency in the
53	production and delivery of health services.
54	(2)  DEFINITIONS.-As used in this section, the term:
55	(a)  "Corporation" means the Florida Health Choices, Inc.,
56	established under this section.
57	(b)  "Corporation's marketplace" means the single,
58	centralized market established by the program that facilitates
59	the purchase of products made available in the marketplace.
60	(c)(b)  "Health insurance agent" means an agent licensed
61	under part IV of chapter 626.
62	(d)(c)  "Insurer" means an entity licensed under chapter
63	624 which offers an individual health insurance policy or a
64	group health insurance policy, a preferred provider organization
65	as defined in s. 627.6471, or an exclusive provider organization
66	as defined in s. 627.6472, or a health maintenance organization
67	licensed under part I of chapter 641, or a prepaid limited
68	health service organization or discount medical plan
69	organization licensed under chapter 636.
70	(e)(d)  "Program" means the Florida Health Choices Program
71	established by this section.
72	(3)  PROGRAM PURPOSE AND COMPONENTS.-The Florida Health
73	Choices Program is created as a single, centralized market for
74	the sale and purchase of various products that enable
75	individuals to pay for health care. These products include, but
76	are not limited to, health insurance plans, health maintenance
77	organization plans, prepaid services, service contracts, and
78	flexible spending accounts. The components of the program
79	include:
80	(a)  Enrollment of employers.
81	(b)  Administrative services for participating employers,
82	including:
83	1.  Assistance in seeking federal approval of cafeteria
84	plans.
85	2.  Collection of premiums and other payments.
86	3.  Management of individual benefit accounts.
87	4.  Distribution of premiums to insurers and payments to
88	other eligible vendors.
89	5.  Assistance for participants in complying with reporting
90	requirements.
91	(c)  Services to individual participants, including:
92	1.  Information about available products and participating
93	vendors.
94	2.  Assistance with assessing the benefits and limits of
95	each product, including information necessary to distinguish
96	between policies offering creditable coverage and other products
97	available through the program.
98	3.  Account information to assist individual participants
99	with managing available resources.
100	4.  Services that promote healthy behaviors.
101	(d)  Recruitment of vendors, including insurers, health
102	maintenance organizations, prepaid clinic service providers,
103	provider service networks, and other providers.
104	(e)  Certification of vendors to ensure capability,
105	reliability, and validity of offerings.
106	(f)  Collection of data, monitoring, assessment, and
107	reporting of vendor performance.
108	(g)  Information services for individuals and employers.
109	(h)  Program evaluation.
110	(4)  ELIGIBILITY AND PARTICIPATION.-Participation in the
111	program is voluntary and shall be available to employers,
112	individuals, vendors, and health insurance agents as specified
113	in this subsection.
114	(a)  Employers eligible to enroll in the program include:
115	1.  Employers that meet criteria established by the
116	corporation and elect to make their employees eligible through
117	the program have 1 to 50 employees.
118	2.  Fiscally constrained counties described in s. 218.67.
119	3.  Municipalities having populations of fewer than 50,000
120	residents.
121	4.  School districts in fiscally constrained counties.
122	5.  Statutory rural hospitals.
123	(b)  Individuals eligible to participate in the program
124	include:
125	1.  Individual employees of enrolled employers.
126	2.  State employees not eligible for state employee health
127	benefits.
128	3.  State retirees.
129	4.  Medicaid reform participants who opt out select the
130	opt-out provision of reform.
131	5.  Statutory rural hospitals.
132	(c)  Employers who choose to participate in the program may
133	enroll by complying with the procedures established by the
134	corporation. The procedures must include, but are not limited
135	to:
136	1.  Submission of required information.
137	2.  Compliance with federal tax requirements for the
138	establishment of a cafeteria plan, pursuant to s. 125 of the
139	Internal Revenue Code, including designation of the employer's
140	plan as a premium payment plan, a salary reduction plan that has
141	flexible spending arrangements, or a salary reduction plan that
142	has a premium payment and flexible spending arrangements.
143	3.  Determination of the employer's contribution, if any,
144	per employee, provided that such contribution is equal for each
145	eligible employee.
146	4.  Establishment of payroll deduction procedures, subject
147	to the agreement of each individual employee who voluntarily
148	participates in the program.
149	5.  Designation of the corporation as the third-party
150	administrator for the employer's health benefit plan.
151	6.  Identification of eligible employees.
152	7.  Arrangement for periodic payments.
153	8.  Employer notification to employees of the intent to
154	transfer from an existing employee health plan to the program at
155	least 90 days before the transition.
156	(d)  All eligible vendors who choose to participate and the
157	products and services that the vendors are permitted to sell are
158	as follows:
159	1.  Insurers licensed under chapter 624 may sell health
160	insurance policies, limited benefit policies, other risk-bearing
161	coverage, and other products or services.
162	2.  Health maintenance organizations licensed under part I
163	of chapter 641 may sell health maintenance contracts insurance
164	policies, limited benefit policies, other risk-bearing products,
165	and other products or services.
166	3.  Prepaid limited health service organizations may sell
167	products and services as authorized under part I of chapter 636,
168	and discount medical plan organizations may sell products and
169	services as authorized under part II of chapter 636.
170	4.3.  Prepaid health clinic service providers licensed
171	under part II of chapter 641 may sell prepaid service contracts
172	and other arrangements for a specified amount and type of health
173	services or treatments.
174	5.4.  Health care providers, including hospitals and other
175	licensed health facilities, health care clinics, licensed health
176	professionals, pharmacies, and other licensed health care
177	providers, may sell service contracts and arrangements for a
178	specified amount and type of health services or treatments.
179	6.5.  Provider organizations, including service networks,
180	group practices, professional associations, and other
181	incorporated organizations of providers, may sell service
182	contracts and arrangements for a specified amount and type of
183	health services or treatments.
184	7.6.  Corporate entities providing specific health services
185	in accordance with applicable state law may sell service
186	contracts and arrangements for a specified amount and type of
187	health services or treatments.
188
189	A vendor described in subparagraphs 3.-7. 3.-6. may not sell
190	products that provide risk-bearing coverage unless that vendor
191	is authorized under a certificate of authority issued by the
192	Office of Insurance Regulation and is authorized to provide
193	coverage in the relevant geographic area under the provisions of
194	the Florida Insurance Code. Otherwise eligible vendors may be
195	excluded from participating in the program for deceptive or
196	predatory practices, financial insolvency, or failure to comply
197	with the terms of the participation agreement or other standards
198	set by the corporation.
199	(e)  Eligible individuals may voluntarily continue
200	participation in the program regardless of subsequent changes in
201	job status or Medicaid eligibility. Individuals who join the
202	program may participate by complying with the procedures
203	established by the corporation. These procedures must include,
204	but are not limited to:
205	1.  Submission of required information.
206	2.  Authorization for payroll deduction.
207	3.  Compliance with federal tax requirements.
208	4.  Arrangements for payment in the event of job changes.
209	5.  Selection of products and services.
210	(f)  Vendors who choose to participate in the program may
211	enroll by complying with the procedures established by the
212	corporation. These procedures may must include, but are not
213	limited to:
214	1.  Submission of required information, including a
215	complete description of the coverage, services, provider
216	network, payment restrictions, and other requirements of each
217	product offered through the program.
218	2.  Execution of an agreement to make all risk-bearing
219	products offered through the program guaranteed-issue policies,
220	subject to preexisting condition exclusions established comply
221	with requirements established by the corporation.
222	3.  Execution of an agreement that prohibits refusal to
223	sell any offered non-risk-bearing product to a participant who
224	elects to buy it.
225	4.  Establishment of product prices based on age, gender,
226	and location of the individual participant, which may include
227	medical underwriting.
228	5.  Arrangements for receiving payment for enrolled
229	participants.
230	6.  Participation in ongoing reporting processes
231	established by the corporation.
232	7.  Compliance with grievance procedures established by the
233	corporation.
234	(g)  Health insurance agents licensed under part IV of
235	chapter 626 are eligible to voluntarily participate as buyers'
236	representatives. A buyer's representative acts on behalf of an
237	individual purchasing health insurance and health services
238	through the program by providing information about products and
239	services available through the program and assisting the
240	individual with both the decision and the procedure of selecting
241	specific products. Serving as a buyer's representative does not
242	constitute a conflict of interest with continuing
243	responsibilities as a health insurance agent if the relationship
244	between each agent and any participating vendor is disclosed
245	before advising an individual participant about the products and
246	services available through the program. In order to participate,
247	a health insurance agent shall comply with the procedures
248	established by the corporation, including:
249	1.  Completion of training requirements.
250	2.  Execution of a participation agreement specifying the
251	terms and conditions of participation.
252	3.  Disclosure of any appointments to solicit insurance or
253	procure applications for vendors participating in the program.
254	4.  Arrangements to receive payment from the corporation
255	for services as a buyer's representative.
256	(5)  PRODUCTS.-
257	(a)  The products that may be made available for purchase
258	through the program include, but are not limited to:
259	1.  Health insurance policies.
260	2.  Health maintenance contracts.
261	3.2.  Limited benefit plans.
262	4.3.  Prepaid clinic services.
263	5.4.  Service contracts.
264	6.5.  Arrangements for purchase of specific amounts and
265	types of health services and treatments.
266	7.6.  Flexible spending accounts.
267	(b)  Health insurance policies, health maintenance
268	contracts, limited benefit plans, prepaid service contracts, and
269	other contracts for services must ensure the availability of
270	covered services and benefits to participating individuals for
271	at least 1 full enrollment year.
272	(c)  Products may be offered for multiyear periods provided
273	the price of the product is specified for the entire period or
274	for each separately priced segment of the policy or contract.
275	(d)  The corporation shall provide a disclosure form for
276	consumers to acknowledge their understanding of the nature of,
277	and any limitations to, the benefits provided by the products
278	and services being purchased by the consumer.
279	(e)  The corporation must determine that making the plan
280	available through the program is in the interest of eligible
281	individuals and eligible employers in the state.
282	(6)  PRICING.-Prices for the products and services sold
283	through the program must be transparent to participants and
284	established by the vendors. based on age, gender, and location
285	of participants. The corporation shall develop a methodology for
286	evaluating the actuarial soundness of products offered through
287	the program. The methodology shall be reviewed by the Office of
288	Insurance Regulation prior to use by the corporation. Before
289	making the product available to individual participants, the
290	corporation shall use the methodology to compare the expected
291	health care costs for the covered services and benefits to the
292	vendor's price for that coverage. The results shall be reported
293	to individuals participating in the program. Once established,
294	the price set by the vendor must remain in force for at least 1
295	year and may only be redetermined by the vendor at the next
296	annual enrollment period. The corporation shall annually assess
297	a surcharge for each premium or price set by a participating
298	vendor. The surcharge may not be more than 2.5 percent of the
299	price and shall be used to generate funding for administrative
300	services provided by the corporation and payments to buyers'
301	representatives.
302	(7)  THE MARKETPLACE EXCHANGE PROCESS.-The program shall
303	provide a single, centralized market for purchase of health
304	insurance, health maintenance contracts, and other health
305	products and services. Purchases may be made by participating
306	individuals over the Internet or through the services of a
307	participating health insurance agent. Information about each
308	product and service available through the program shall be made
309	available through printed material and an interactive Internet
310	website. A participant needing personal assistance to select
311	products and services shall be referred to a participating agent
312	in his or her area.
313	(a)  Participation in the program may begin at any time
314	during a year after the employer completes enrollment and meets
315	the requirements specified by the corporation pursuant to
316	paragraph (4)(c).
317	(b)  Initial selection of products and services must be
318	made by an individual participant within 60 days after the date
319	the individual's employer qualified for participation. An
320	individual who fails to enroll in products and services by the
321	end of this period is limited to participation in flexible
322	spending account services until the next annual enrollment
323	period.
324	(c)  Initial enrollment periods for each product selected
325	by an individual participant must last at least 12 months,
326	unless the individual participant specifically agrees to a
327	different enrollment period.
328	(d)  If an individual has selected one or more products and
329	enrolled in those products for at least 12 months or any other
330	period specifically agreed to by the individual participant,
331	changes in selected products and services may only be made
332	during the annual enrollment period established by the
333	corporation.
334	(e)  The limits established in paragraphs (b)-(d) apply to
335	any risk-bearing product that promises future payment or
336	coverage for a variable amount of benefits or services. The
337	limits do not apply to initiation of flexible spending plans if
338	those plans are not associated with specific high-deductible
339	insurance policies or the use of spending accounts for any
340	products offering individual participants specific amounts and
341	types of health services and treatments at a contracted price.
342	(8)  CONSUMER INFORMATION.-The corporation shall:
343	(a)  Establish a secure website to facilitate the purchase
344	of products and services by participating individuals. The
345	website must provide information about each product or service
346	available through the program.
347	(b)  Inform individuals about other public health care
348	programs.
349	(a)  Prior to making a risk-bearing product available
350	through the program, the corporation shall provide information
351	regarding the product to the Office of Insurance Regulation. The
352	office shall review the product information and provide consumer
353	information and a recommendation on the risk-bearing product to
354	the corporation within 30 days after receiving the product
355	information.
356	1.  Upon receiving a recommendation that a risk-bearing
357	product should be made available in the marketplace, the
358	corporation may include the product on its website. If the
359	consumer information and recommendation is not received within
360	30 days, the corporation may make the risk-bearing product
361	available on the website without consumer information from the
362	office.
363	2.  Upon receiving a recommendation that a risk-bearing
364	product should not be made available in the marketplace, the
365	risk-bearing product may be included as an eligible product in
366	the marketplace and on its website only if a majority of the
367	board of directors vote to include the product.
368	(b)  If a risk-bearing product is made available on the
369	website, the corporation shall make the consumer information and
370	office recommendation available on the website and in print
371	format. The corporation shall make late-submitted and ongoing
372	updates to consumer information available on the website and in
373	print format.
374	(9)  RISK POOLING.-The program may use shall utilize
375	methods for pooling the risk of individual participants and
376	preventing selection bias. These methods may shall include, but
377	are not limited to, a postenrollment risk adjustment of the
378	premium payments to the vendors. The corporation may shall
379	establish a methodology for assessing the risk of enrolled
380	individual participants based on data reported annually by the
381	vendors about their enrollees. Distribution Monthly
382	distributions of payments to the vendors may shall be adjusted
383	based on the assessed relative risk profile of the enrollees in
384	each risk-bearing product for the most recent period for which
385	data is available.
386	(10)  EXEMPTIONS.-
387	(a)  Products, other than the products set forth in
388	subparagraph (4)(d)1.-4., Policies sold as part of the program
389	are not subject to the licensing requirements of the Florida
390	Insurance Code, as defined in s. 624.01 chapter 641, or the
391	mandated offerings or coverages established in part VI of
392	chapter 627 and chapter 641.
393	(b)  The corporation may act as an administrator as defined
394	in s. 626.88 but is not required to be certified pursuant to
395	part VII of chapter 626. However, a third party administrator
396	used by the corporation must be certified under part VII of
397	chapter 626.
398	(11)  CORPORATION.-There is created the Florida Health
399	Choices, Inc., which shall be registered, incorporated,
400	organized, and operated in compliance with part III of chapter
401	112 and chapters 119, 286, and 617. The purpose of the
402	corporation is to administer the program created in this section
403	and to conduct such other business as may further the
404	administration of the program.
405	(a)  The corporation shall be governed by a 15-member board
406	of directors consisting of:
407	1.  Three ex officio, nonvoting members to include:
408	a.  The Secretary of Health Care Administration or a
409	designee with expertise in health care services.
410	b.  The Secretary of Management Services or a designee with
411	expertise in state employee benefits.
412	c.  The commissioner of the Office of Insurance Regulation
413	or a designee with expertise in insurance regulation.
414	2.  Four members appointed by and serving at the pleasure
415	of the Governor.
416	3.  Four members appointed by and serving at the pleasure
417	of the President of the Senate.
418	4.  Four members appointed by and serving at the pleasure
419	of the Speaker of the House of Representatives.
420	5.  Board members may not include insurers, health
421	insurance agents or brokers, health care providers, health
422	maintenance organizations, prepaid service providers, or any
423	other entity, affiliate or subsidiary of eligible vendors.
424	(b)  Members shall be appointed for terms of up to 3 years.
425	Any member is eligible for reappointment. A vacancy on the board
426	shall be filled for the unexpired portion of the term in the
427	same manner as the original appointment.
428	(c)  The board shall select a chief executive officer for
429	the corporation who shall be responsible for the selection of
430	such other staff as may be authorized by the corporation's
431	operating budget as adopted by the board.
432	(d)  Board members are entitled to receive, from funds of
433	the corporation, reimbursement for per diem and travel expenses
434	as provided by s. 112.061. No other compensation is authorized.
435	(e)  There is no liability on the part of, and no cause of
436	action shall arise against, any member of the board or its
437	employees or agents for any action taken by them in the
438	performance of their powers and duties under this section.
439	(f)  The board shall develop and adopt bylaws and other
440	corporate procedures as necessary for the operation of the
441	corporation and carrying out the purposes of this section. The
442	bylaws shall:
443	1.  Specify procedures for selection of officers and
444	qualifications for reappointment, provided that no board member
445	shall serve more than 9 consecutive years.
446	2.  Require an annual membership meeting that provides an
447	opportunity for input and interaction with individual
448	participants in the program.
449	3.  Specify policies and procedures regarding conflicts of
450	interest, including the provisions of part III of chapter 112,
451	which prohibit a member from participating in any decision that
452	would inure to the benefit of the member or the organization
453	that employs the member. The policies and procedures shall also
454	require public disclosure of the interest that prevents the
455	member from participating in a decision on a particular matter.
456	(g)  The corporation may exercise all powers granted to it
457	under chapter 617 necessary to carry out the purposes of this
458	section, including, but not limited to, the power to receive and
459	accept grants, loans, or advances of funds from any public or
460	private agency and to receive and accept from any source
461	contributions of money, property, labor, or any other thing of
462	value to be held, used, and applied for the purposes of this
463	section.
464	(h)  The corporation may establish technical advisory
465	panels consisting of interested parties, including consumers,
466	health care providers, individuals with expertise in insurance
467	regulation, and insurers.
468	(i)  The corporation shall:
469	1.  Determine eligibility of employers, vendors,
470	individuals, and agents in accordance with subsection (4).
471	2.  Establish procedures necessary for the operation of the
472	program, including, but not limited to, procedures for
473	application, enrollment, risk assessment, risk adjustment, plan
474	administration, performance monitoring, and consumer education.
475	3.  Arrange for collection of contributions from
476	participating employers and individuals.
477	4.  Arrange for payment of premiums and other appropriate
478	disbursements based on the selections of products and services
479	by the individual participants.
480	5.  Establish criteria for disenrollment of participating
481	individuals based on failure to pay the individual's share of
482	any contribution required to maintain enrollment in selected
483	products.
484	6.  Establish criteria for exclusion of vendors pursuant to
485	paragraph (4)(d).
486	7.  Develop and implement a plan for promoting public
487	awareness of and participation in the program.
488	8.  Secure staff and consultant services necessary to the
489	operation of the program.
490	9.  Establish policies and procedures regarding
491	participation in the program for individuals, vendors, health
492	insurance agents, and employers.
493	10.  Provide for the operation of a toll-free hotline to
494	respond to requests for assistance.
495	11.  Provide for initial, open, and special enrollment
496	periods.
497	12.  Evaluate options for employer participation which may
498	conform with common insurance practices.
499	10.  Develop a plan, in coordination with the Department of
500	Revenue, to establish tax credits or refunds for employers that
501	participate in the program. The corporation shall submit the
502	plan to the Governor, the President of the Senate, and the
503	Speaker of the House of Representatives by January 1, 2009.
504	(12)  REPORT.-Beginning in the 2009-2010 fiscal year,
505	submit by February 1 an annual report to the Governor, the
506	President of the Senate, and the Speaker of the House of
507	Representatives documenting the corporation's activities in
508	compliance with the duties delineated in this section.
509	(13)  PROGRAM INTEGRITY.-To ensure program integrity and to
510	safeguard the financial transactions made under the auspices of
511	the program, the corporation is authorized to establish
512	qualifying criteria and certification procedures for vendors,
513	require performance bonds or other guarantees of ability to
514	complete contractual obligations, monitor the performance of
515	vendors, and enforce the agreements of the program through
516	financial penalty or disqualification from the program.
517	Section 2.  Section 409.821, Florida Statutes, is amended
518	to read:
519	409.821  Florida Kidcare program public records exemption.-
520	(1)  Personal identifying information of a Florida Kidcare
521	program applicant or enrollee, as defined in s. 409.811, held by
522	the Agency for Health Care Administration, the Department of
523	Children and Family Services, the Department of Health, or the
524	Florida Healthy Kids Corporation is confidential and exempt from
525	s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
526	(2)(a)  Upon request, such information shall be disclosed
527	to:
528	1.  Another governmental entity in the performance of its
529	official duties and responsibilities;
530	2.  The Department of Revenue for purposes of administering
531	the state Title IV-D program; or
532	3.  The Florida Health Choices, Inc., for the purpose of
533	administering the program authorized pursuant to s. 408.910; or
534	4.3.  Any person who has the written consent of the program
535	applicant.
536	(b)  This section does not prohibit an enrollee's legal
537	guardian from obtaining confirmation of coverage, dates of
538	coverage, the name of the enrollee's health plan, and the amount
539	of premium being paid.
540	(3)  This exemption applies to any information identifying
541	a Florida Kidcare program applicant or enrollee held by the
542	Agency for Health Care Administration, the Department of
543	Children and Family Services, the Department of Health, or the
544	Florida Healthy Kids Corporation before, on, or after the
545	effective date of this exemption.
546	(4)  A knowing and willful violation of this section is a
547	misdemeanor of the second degree, punishable as provided in s.
548	775.082 or s. 775.083.
549	Section 3.  Subsection (41) of section 409.912, Florida
550	Statutes, is amended to read:
551	409.912  Cost-effective purchasing of health care.-The
552	agency shall purchase goods and services for Medicaid recipients
553	in the most cost-effective manner consistent with the delivery
554	of quality medical care. To ensure that medical services are
555	effectively utilized, the agency may, in any case, require a
556	confirmation or second physician's opinion of the correct
557	diagnosis for purposes of authorizing future services under the
558	Medicaid program. This section does not restrict access to
559	emergency services or poststabilization care services as defined
560	in 42 C.F.R. part 438.114. Such confirmation or second opinion
561	shall be rendered in a manner approved by the agency. The agency
562	shall maximize the use of prepaid per capita and prepaid
563	aggregate fixed-sum basis services when appropriate and other
564	alternative service delivery and reimbursement methodologies,
565	including competitive bidding pursuant to s. 287.057, designed
566	to facilitate the cost-effective purchase of a case-managed
567	continuum of care. The agency shall also require providers to
568	minimize the exposure of recipients to the need for acute
569	inpatient, custodial, and other institutional care and the
570	inappropriate or unnecessary use of high-cost services. The
571	agency shall contract with a vendor to monitor and evaluate the
572	clinical practice patterns of providers in order to identify
573	trends that are outside the normal practice patterns of a
574	provider's professional peers or the national guidelines of a
575	provider's professional association. The vendor must be able to
576	provide information and counseling to a provider whose practice
577	patterns are outside the norms, in consultation with the agency,
578	to improve patient care and reduce inappropriate utilization.
579	The agency may mandate prior authorization, drug therapy
580	management, or disease management participation for certain
581	populations of Medicaid beneficiaries, certain drug classes, or
582	particular drugs to prevent fraud, abuse, overuse, and possible
583	dangerous drug interactions. The Pharmaceutical and Therapeutics
584	Committee shall make recommendations to the agency on drugs for
585	which prior authorization is required. The agency shall inform
586	the Pharmaceutical and Therapeutics Committee of its decisions
587	regarding drugs subject to prior authorization. The agency is
588	authorized to limit the entities it contracts with or enrolls as
589	Medicaid providers by developing a provider network through
590	provider credentialing. The agency may competitively bid single-
591	source-provider contracts if procurement of goods or services
592	results in demonstrated cost savings to the state without
593	limiting access to care. The agency may limit its network based
594	on the assessment of beneficiary access to care, provider
595	availability, provider quality standards, time and distance
596	standards for access to care, the cultural competence of the
597	provider network, demographic characteristics of Medicaid
598	beneficiaries, practice and provider-to-beneficiary standards,
599	appointment wait times, beneficiary use of services, provider
600	turnover, provider profiling, provider licensure history,
601	previous program integrity investigations and findings, peer
602	review, provider Medicaid policy and billing compliance records,
603	clinical and medical record audits, and other factors. Providers
604	shall not be entitled to enrollment in the Medicaid provider
605	network. The agency shall determine instances in which allowing
606	Medicaid beneficiaries to purchase durable medical equipment and
607	other goods is less expensive to the Medicaid program than long-
608	term rental of the equipment or goods. The agency may establish
609	rules to facilitate purchases in lieu of long-term rentals in
610	order to protect against fraud and abuse in the Medicaid program
611	as defined in s. 409.913. The agency may seek federal waivers
612	necessary to administer these policies.
613	(41)  The agency shall establish provide for the
614	development of a demonstration project by establishment in
615	Miami-Dade County of a long-term-care facility and a psychiatric
616	facility licensed pursuant to chapter 395 to improve access to
617	health care for a predominantly minority, medically underserved,
618	and medically complex population and to evaluate alternatives to
619	nursing home care and general acute care for such population.
620	Such project is to be located in a health care condominium and
621	collocated colocated with licensed facilities providing a
622	continuum of care. These projects are The establishment of this
623	project is not subject to the provisions of s. 408.036 or s.
624	408.039.
625	Section 4.  This act shall take effect July 1, 2011.

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