HB 1133

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 409.912, F.S.;
3	authorizing the Agency for Health Care Administration, in
4	collaboration with the Department of Health, to develop a
5	home and community-based services Medicaid waiver program
6	to serve children diagnosed with Trisomy 18, subject to
7	federal waiver approval; providing rulemaking authority;
8	providing an effective date.
9
10	Be It Enacted by the Legislature of the State of Florida:
11
12	Section 1.  Subsection (54) is added to section 409.912,
13	Florida Statutes, to read:
14	409.912  Cost-effective purchasing of health care.-The
15	agency shall purchase goods and services for Medicaid recipients
16	in the most cost-effective manner consistent with the delivery
17	of quality medical care. To ensure that medical services are
18	effectively utilized, the agency may, in any case, require a
19	confirmation or second physician's opinion of the correct
20	diagnosis for purposes of authorizing future services under the
21	Medicaid program. This section does not restrict access to
22	emergency services or poststabilization care services as defined
23	in 42 C.F.R. part 438.114. Such confirmation or second opinion
24	shall be rendered in a manner approved by the agency. The agency
25	shall maximize the use of prepaid per capita and prepaid
26	aggregate fixed-sum basis services when appropriate and other
27	alternative service delivery and reimbursement methodologies,
28	including competitive bidding pursuant to s. 287.057, designed
29	to facilitate the cost-effective purchase of a case-managed
30	continuum of care. The agency shall also require providers to
31	minimize the exposure of recipients to the need for acute
32	inpatient, custodial, and other institutional care and the
33	inappropriate or unnecessary use of high-cost services. The
34	agency shall contract with a vendor to monitor and evaluate the
35	clinical practice patterns of providers in order to identify
36	trends that are outside the normal practice patterns of a
37	provider's professional peers or the national guidelines of a
38	provider's professional association. The vendor must be able to
39	provide information and counseling to a provider whose practice
40	patterns are outside the norms, in consultation with the agency,
41	to improve patient care and reduce inappropriate utilization.
42	The agency may mandate prior authorization, drug therapy
43	management, or disease management participation for certain
44	populations of Medicaid beneficiaries, certain drug classes, or
45	particular drugs to prevent fraud, abuse, overuse, and possible
46	dangerous drug interactions. The Pharmaceutical and Therapeutics
47	Committee shall make recommendations to the agency on drugs for
48	which prior authorization is required. The agency shall inform
49	the Pharmaceutical and Therapeutics Committee of its decisions
50	regarding drugs subject to prior authorization. The agency is
51	authorized to limit the entities it contracts with or enrolls as
52	Medicaid providers by developing a provider network through
53	provider credentialing. The agency may competitively bid single-
54	source-provider contracts if procurement of goods or services
55	results in demonstrated cost savings to the state without
56	limiting access to care. The agency may limit its network based
57	on the assessment of beneficiary access to care, provider
58	availability, provider quality standards, time and distance
59	standards for access to care, the cultural competence of the
60	provider network, demographic characteristics of Medicaid
61	beneficiaries, practice and provider-to-beneficiary standards,
62	appointment wait times, beneficiary use of services, provider
63	turnover, provider profiling, provider licensure history,
64	previous program integrity investigations and findings, peer
65	review, provider Medicaid policy and billing compliance records,
66	clinical and medical record audits, and other factors. Providers
67	shall not be entitled to enrollment in the Medicaid provider
68	network. The agency shall determine instances in which allowing
69	Medicaid beneficiaries to purchase durable medical equipment and
70	other goods is less expensive to the Medicaid program than long-
71	term rental of the equipment or goods. The agency may establish
72	rules to facilitate purchases in lieu of long-term rentals in
73	order to protect against fraud and abuse in the Medicaid program
74	as defined in s. 409.913. The agency may seek federal waivers
75	necessary to administer these policies.
76	(54)  The agency shall work with the Department of Health
77	to develop a home and community-based services Medicaid waiver
78	program to serve children diagnosed with Trisomy 18, also known
79	as Edwards syndrome, a rare genetic disorder that is
80	characterized by heart abnormalities, kidney dysfunction, and
81	other internal disorders. The agency shall implement the program
82	subject to federal waiver approval, the availability of funds,
83	and any limitations provided in the General Appropriations Act.
84	The agency may adopt rules to implement this subsection.
85	Section 2.  This act shall take effect July 1, 2011.

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