Florida Senate - 2011 CS for SB 1922
By the Committee on Banking and Insurance; and Senator Garcia
597-04914-11 20111922c1
1 A bill to be entitled
2 An act relating to health and human services; amending
3 s. 408.910, F.S.; providing and revising definitions;
4 revising eligibility requirements for participation in
5 the Florida Health Choices Program; providing that
6 statutory rural hospitals are eligible as employers
7 rather than participants under the program; permitting
8 specified eligible vendors to sell health maintenance
9 contracts or products and services; requiring certain
10 risk-bearing products offered by insurers to be
11 approved by the Office of Insurance Regulation;
12 providing requirements for product certification;
13 providing duties of the Florida Health Choices, Inc.,
14 including maintenance of a toll-free telephone hotline
15 to respond to requests for assistance; providing for
16 enrollment periods; providing for certain risk pooling
17 data used by the corporation to be reported annually;
18 amending s. 409.821, F.S.; authorizing personal
19 identifying information of a Florida Kidcare program
20 applicant to be disclosed to the Florida Health
21 Choices, Inc., to administer the program; amending s.
22 409.912, F.S.; requiring the Agency for Health Care
23 Administration to establish a demonstration project in
24 Miami-Dade County of a long-term-care facility and a
25 psychiatric facility to improve access to health care
26 by medically underserved persons; providing an
27 effective date.
28
29 Be It Enacted by the Legislature of the State of Florida:
30
31 Section 1. Section 408.910, Florida Statutes, is amended to
32 read:
33 408.910 Florida Health Choices Program.—
34 (1) LEGISLATIVE INTENT.—The Legislature finds that a
35 significant number of the residents of this state do not have
36 adequate access to affordable, quality health care. The
37 Legislature further finds that increasing access to affordable,
38 quality health care can be best accomplished by establishing a
39 competitive market for purchasing health insurance and health
40 services. It is therefore the intent of the Legislature to
41 create the Florida Health Choices Program to:
42 (a) Expand opportunities for Floridians to purchase
43 affordable health insurance and health services.
44 (b) Preserve the benefits of employment-sponsored insurance
45 while easing the administrative burden for employers who offer
46 these benefits.
47 (c) Enable individual choice in both the manner and amount
48 of health care purchased.
49 (d) Provide for the purchase of individual, portable health
50 care coverage.
51 (e) Disseminate information to consumers on the price and
52 quality of health services.
53 (f) Sponsor a competitive market that stimulates product
54 innovation, quality improvement, and efficiency in the
55 production and delivery of health services.
56 (2) DEFINITIONS.—As used in this section, the term:
57 (a) “Corporation” means the Florida Health Choices, Inc.,
58 established under this section.
59 (b) “Corporation’s marketplace” means the single,
60 centralized market established by the program which facilitates
61 the purchase of products made available in the marketplace.
62 (c)(b) “Health insurance agent” means an agent licensed
63 under part IV of chapter 626.
64 (d)(c) “Insurer” means an entity licensed under chapter 624
65 which offers an individual health insurance policy or a group
66 health insurance policy, a preferred provider organization as
67 defined in s. 627.6471, or an exclusive provider organization as
68 defined in s. 627.6472, a health maintenance organization
69 licensed under part I of chapter 641, or a prepaid limited
70 health service organization or discount medical plan
71 organization licensed under chapter 636.
72 (e)(d) “Program” means the Florida Health Choices Program
73 established by this section.
74 (3) PROGRAM PURPOSE AND COMPONENTS.—The Florida Health
75 Choices Program is created as a single, centralized market for
76 the sale and purchase of various products that enable
77 individuals to pay for health care. These products include, but
78 are not limited to, health insurance plans, health maintenance
79 organization plans, prepaid services, service contracts, and
80 flexible spending accounts. The components of the program
81 include:
82 (a) Enrollment of employers.
83 (b) Administrative services for participating employers,
84 including:
85 1. Assistance in seeking federal approval of cafeteria
86 plans.
87 2. Collection of premiums and other payments.
88 3. Management of individual benefit accounts.
89 4. Distribution of premiums to insurers and payments to
90 other eligible vendors.
91 5. Assistance for participants in complying with reporting
92 requirements.
93 (c) Services to individual participants, including:
94 1. Information about available products and participating
95 vendors.
96 2. Assistance with assessing the benefits and limits of
97 each product, including information necessary to distinguish
98 between policies offering creditable coverage and other products
99 available through the program.
100 3. Account information to assist individual participants
101 with managing available resources.
102 4. Services that promote healthy behaviors.
103 (d) Recruitment of vendors, including insurers, health
104 maintenance organizations, prepaid clinic service providers,
105 provider service networks, and other providers.
106 (e) Certification of vendors to ensure capability,
107 reliability, and validity of offerings.
108 (f) Collection of data, monitoring, assessment, and
109 reporting of vendor performance.
110 (g) Information services for individuals and employers.
111 (h) Program evaluation.
112 (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
113 program is voluntary and is shall be available to employers,
114 individuals, vendors, and health insurance agents as specified
115 in this subsection.
116 (a) Employers eligible to enroll in the program include:
117 1. Employers that meet criteria established by the
118 corporation and elect to make their employees eligible for one
119 or more health products offered through the program have 1 to 50
120 employees.
121 2. Fiscally constrained counties described in s. 218.67.
122 3. Municipalities having populations of fewer than 50,000
123 residents.
124 4. School districts in fiscally constrained counties.
125 5. Statutory rural hospitals.
126 (b) Individuals eligible to participate in the program
127 include:
128 1. Individual employees of enrolled employers.
129 2. State employees not eligible for state employee health
130 benefits.
131 3. State retirees.
132 4. Medicaid reform participants who opt out select the opt
133 out provision of reform.
134 5. Statutory rural hospitals.
135 (c) Employers who choose to participate in the program may
136 enroll by complying with the procedures established by the
137 corporation. The procedures must include, but are not limited
138 to:
139 1. Submission of required information.
140 2. Compliance with federal tax requirements for the
141 establishment of a cafeteria plan, pursuant to s. 125 of the
142 Internal Revenue Code, including designation of the employer’s
143 plan as a premium payment plan, a salary reduction plan that has
144 flexible spending arrangements, or a salary reduction plan that
145 has a premium payment and flexible spending arrangements.
146 3. Determination of the employer’s contribution, if any,
147 per employee, provided that such contribution is equal for each
148 eligible employee.
149 4. Establishment of payroll deduction procedures, subject
150 to the agreement of each individual employee who voluntarily
151 participates in the program.
152 5. Designation of the corporation as the third-party
153 administrator for the employer’s health benefit plan.
154 6. Identification of eligible employees.
155 7. Arrangement for periodic payments.
156 8. Employer notification to employees of the intent to
157 transfer from an existing employee health plan to the program at
158 least 90 days before the transition.
159 (d) All eligible vendors who choose to participate and the
160 products and services that the vendors are permitted to sell are
161 as follows:
162 1. Insurers licensed under chapter 624 may sell health
163 insurance policies, limited benefit policies, other risk-bearing
164 coverage, and other products or services.
165 2. Health maintenance organizations licensed under part I
166 of chapter 641 may sell health maintenance contracts insurance
167 policies, limited benefit policies, other risk-bearing products,
168 and other products or services.
169 3. Prepaid limited health service organizations may sell
170 products and services as authorized under part I of chapter 636,
171 and discount medical plan organizations may sell products and
172 services as authorized under part II of chapter 636.
173 4.3. Prepaid health clinic service providers licensed under
174 part II of chapter 641 may sell prepaid service contracts and
175 other arrangements for a specified amount and type of health
176 services or treatments.
177 5.4. Health care providers, including hospitals and other
178 licensed health facilities, health care clinics, licensed health
179 professionals, pharmacies, and other licensed health care
180 providers, may sell service contracts and arrangements for a
181 specified amount and type of health services or treatments.
182 6.5. Provider organizations, including service networks,
183 group practices, professional associations, and other
184 incorporated organizations of providers, may sell service
185 contracts and arrangements for a specified amount and type of
186 health services or treatments.
187 7.6. Corporate entities providing specific health services
188 in accordance with applicable state law may sell service
189 contracts and arrangements for a specified amount and type of
190 health services or treatments.
191
192 A vendor described in subparagraphs 4.-7. 3.-6. may not sell
193 products that provide risk-bearing coverage unless that vendor
194 is authorized under a certificate of authority issued by the
195 Office of Insurance Regulation and is authorized to provide
196 coverage in the relevant geographic area under the provisions of
197 the Florida Insurance Code. Otherwise eligible vendors may be
198 excluded from participating in the program for deceptive or
199 predatory practices, financial insolvency, or failure to comply
200 with the terms of the participation agreement or other standards
201 set by the corporation.
202 (e) Any risk-bearing product available under subparagraphs
203 (d)1.-4. must be approved by the Office of Insurance Regulation.
204 Any non-risk-bearing product must be approved by the
205 corporation.
206 (f)(e) Eligible individuals may voluntarily continue
207 participation in the program regardless of subsequent changes in
208 job status or Medicaid eligibility. Individuals who join the
209 program may participate by complying with the procedures
210 established by the corporation. These procedures must include,
211 but are not limited to:
212 1. Submission of required information.
213 2. Authorization for payroll deduction.
214 3. Compliance with federal tax requirements.
215 4. Arrangements for payment in the event of job changes.
216 5. Selection of products and services.
217 (g)(f) Vendors who choose to participate in the program may
218 enroll by complying with the procedures established by the
219 corporation. These procedures may must include, but are not
220 limited to:
221 1. Submission of required information, including a complete
222 description of the coverage, services, provider network, payment
223 restrictions, and other requirements of each product offered
224 through the program.
225 2. Execution of an agreement that to make all risk-bearing
226 products offered through the program are in compliance with the
227 insurance code and are guaranteed-issue policies, subject to
228 preexisting condition exclusions established by the corporation.
229 3. Execution of an agreement that prohibits refusal to sell
230 any offered non-risk-bearing product to a participant who elects
231 to buy it.
232 4. Establishment of product prices based on age, gender,
233 family composition, and location of the individual participant,
234 which may include medical underwriting.
235 5. Arrangements for receiving payment for enrolled
236 participants.
237 6. Participation in ongoing reporting processes established
238 by the corporation.
239 7. Compliance with grievance procedures established by the
240 corporation.
241 (h)(g) Health insurance agents licensed under part IV of
242 chapter 626 are eligible to voluntarily participate as buyers’
243 representatives. A buyer’s representative acts on behalf of an
244 individual purchasing health insurance and health services
245 through the program by providing information about products and
246 services available through the program and assisting the
247 individual with both the decision and the procedure of selecting
248 specific products. Serving as a buyer’s representative does not
249 constitute a conflict of interest with continuing
250 responsibilities as a health insurance agent if the relationship
251 between each agent and any participating vendor is disclosed
252 before advising an individual participant about the products and
253 services available through the program. In order to participate,
254 a health insurance agent shall comply with the procedures
255 established by the corporation, including:
256 1. Completion of training requirements.
257 2. Execution of a participation agreement specifying the
258 terms and conditions of participation.
259 3. Disclosure of any appointments to solicit insurance or
260 procure applications for vendors participating in the program.
261 4. Arrangements to receive payment from the corporation for
262 services as a buyer’s representative.
263 (5) PRODUCTS.—
264 (a) The products that may be made available for purchase
265 through the program include, but are not limited to:
266 1. Health insurance policies.
267 2. Limited benefit plans.
268 3. Prepaid clinic services.
269 4. Service contracts.
270 5. Arrangements for purchase of specific amounts and types
271 of health services and treatments.
272 6. Flexible spending accounts.
273 7. Health maintenance contracts.
274 (b) Health insurance policies, health maintenance
275 contracts, limited benefit plans, prepaid service contracts, and
276 other contracts for services must ensure the availability of
277 covered services and benefits to participating individuals for
278 at least 1 full enrollment year.
279 (c) Products may be offered for multiyear periods provided
280 the price of the product is specified for the entire period or
281 for each separately priced segment of the policy or contract.
282 (d) The corporation shall provide a disclosure form for
283 consumers to acknowledge their understanding of the nature of,
284 and any limitations to, the benefits provided by the products
285 and services being purchased by the consumer.
286 (e) The corporation must determine that making the plan
287 available through the program is in the interest of eligible
288 individuals and eligible employers in the state.
289 (6) PRICING.—Prices for the products sold through the
290 program must be transparent to participants and established by
291 the vendors. Risk-bearing products approved by the Office of
292 Insurance Regulation must be priced pursuant to state law
293 governing the rates of insurance product based on age, gender,
294 and location of participants. The corporation shall develop a
295 methodology for evaluating the actuarial soundness of products
296 offered through the program. The methodology shall be reviewed
297 by the Office of Insurance Regulation prior to use by the
298 corporation. Before making the product available to individual
299 participants, the corporation shall use the methodology to
300 compare the expected health care costs for the covered services
301 and benefits to the vendor’s price for that coverage. The
302 results shall be reported to individuals participating in the
303 program. Once established, the price set by the vendor must
304 remain in force for at least 1 year and may only be redetermined
305 by the vendor at the next annual enrollment period. The
306 corporation shall annually assess a surcharge for each premium
307 or price set by a participating vendor. The surcharge may not be
308 more than 2.5 percent of the price and shall be used to generate
309 funding for administrative services provided by the corporation
310 and payments to buyers’ representatives.
311 (7) MARKETPLACE EXCHANGE PROCESS.—The program shall provide
312 a single, centralized market for purchase of health insurance,
313 health maintenance contracts, and other health products and
314 services. Purchases may be made by participating individuals
315 over the Internet or through the services of a participating
316 health insurance agent. Information about each product and
317 service available through the program shall be made available
318 through printed material and an interactive Internet website. A
319 participant needing personal assistance to select products and
320 services shall be referred to a participating agent in his or
321 her area.
322 (a) Participation in the program may begin at any time
323 during a year after the employer completes enrollment and meets
324 the requirements specified by the corporation pursuant to
325 paragraph (4)(c).
326 (b) Initial selection of products and services must be made
327 by an individual participant within 60 days after the date the
328 individual’s employer qualified for participation. An individual
329 who fails to enroll in products and services by the end of this
330 period is limited to participation in flexible spending account
331 services until the next annual enrollment period.
332 (c) Initial enrollment periods for each product selected by
333 an individual participant must last at least 12 months, unless
334 the individual participant specifically agrees to a different
335 enrollment period.
336 (d) If an individual has selected one or more products and
337 enrolled in those products for at least 12 months or any other
338 period specifically agreed to by the individual participant,
339 changes in selected products and services may only be made
340 during the annual enrollment period established by the
341 corporation.
342 (e) The limits established in paragraphs (b)-(d) apply to
343 any risk-bearing product that promises future payment or
344 coverage for a variable amount of benefits or services. The
345 limits do not apply to initiation of flexible spending plans if
346 those plans are not associated with specific high-deductible
347 insurance policies or the use of spending accounts for any
348 products offering individual participants specific amounts and
349 types of health services and treatments at a contracted price.
350 (8) CONSUMER INFORMATION.—The corporation shall:
351 (a) Establish a secure website to facilitate the purchase
352 of products and services by participating individuals. The
353 website must provide information about each product or service
354 available through the program.
355 (b) Inform individuals about other public health care
356 programs.
357 (a) Prior to making a risk-bearing product available
358 through the program, the corporation shall provide information
359 regarding the product to the Office of Insurance Regulation. The
360 office shall review the product information and provide consumer
361 information and a recommendation on the risk-bearing product to
362 the corporation within 30 days after receiving the product
363 information.
364 1. Upon receiving a recommendation that a risk-bearing
365 product should be made available in the marketplace, the
366 corporation may include the product on its website. If the
367 consumer information and recommendation is not received within
368 30 days, the corporation may make the risk-bearing product
369 available on the website without consumer information from the
370 office.
371 2. Upon receiving a recommendation that a risk-bearing
372 product should not be made available in the marketplace, the
373 risk-bearing product may be included as an eligible product in
374 the marketplace and on its website only if a majority of the
375 board of directors vote to include the product.
376 (b) If a risk-bearing product is made available on the
377 website, the corporation shall make the consumer information and
378 office recommendation available on the website and in print
379 format. The corporation shall make late-submitted and ongoing
380 updates to consumer information available on the website and in
381 print format.
382 (9) RISK POOLING.—The program may use shall utilize methods
383 for pooling the risk of individual participants and preventing
384 selection bias. These methods may shall include, but are not
385 limited to, a postenrollment risk adjustment of the premium
386 payments to the vendors. The corporation may shall establish a
387 methodology for assessing the risk of enrolled individual
388 participants based on data reported annually by the vendors
389 about their enrollees. Distribution Monthly distributions of
390 payments to the vendors may shall be adjusted based on the
391 assessed relative risk profile of the enrollees in each risk
392 bearing product for the most recent period for which data is
393 available.
394 (10) EXEMPTIONS.—
395 (a) Products, other than the risk-bearing products set
396 forth in subparagraph (4)(d)1.-4., Policies sold as part of the
397 program are not subject to the licensing requirements of the
398 Florida Insurance Code, as defined in s. 624.01 chapter 641, or
399 the mandated offerings or coverages established in part VI of
400 chapter 627 and chapter 641.
401 (b) The corporation may act as an administrator as defined
402 in s. 626.88 but is not required to be certified pursuant to
403 part VII of chapter 626. However, a third party administrator
404 used by the corporation must be certified under part VII of
405 chapter 626.
406 (11) CORPORATION.—There is created the Florida Health
407 Choices, Inc., which shall be registered, incorporated,
408 organized, and operated in compliance with part III of chapter
409 112 and chapters 119, 286, and 617. The purpose of the
410 corporation is to administer the program created in this section
411 and to conduct such other business as may further the
412 administration of the program.
413 (a) The corporation shall be governed by a 15-member board
414 of directors consisting of:
415 1. Three ex officio, nonvoting members to include:
416 a. The Secretary of Health Care Administration or a
417 designee with expertise in health care services.
418 b. The Secretary of Management Services or a designee with
419 expertise in state employee benefits.
420 c. The commissioner of the Office of Insurance Regulation
421 or a designee with expertise in insurance regulation.
422 2. Four members appointed by and serving at the pleasure of
423 the Governor.
424 3. Four members appointed by and serving at the pleasure of
425 the President of the Senate.
426 4. Four members appointed by and serving at the pleasure of
427 the Speaker of the House of Representatives.
428 5. Board members may not include insurers, health insurance
429 agents or brokers, health care providers, health maintenance
430 organizations, prepaid service providers, or any other entity,
431 affiliate or subsidiary of eligible vendors.
432 (b) Members shall be appointed for terms of up to 3 years.
433 Any member is eligible for reappointment. A vacancy on the board
434 shall be filled for the unexpired portion of the term in the
435 same manner as the original appointment.
436 (c) The board shall select a chief executive officer for
437 the corporation who shall be responsible for the selection of
438 such other staff as may be authorized by the corporation’s
439 operating budget as adopted by the board.
440 (d) Board members are entitled to receive, from funds of
441 the corporation, reimbursement for per diem and travel expenses
442 as provided by s. 112.061. No other compensation is authorized.
443 (e) There is no liability on the part of, and no cause of
444 action shall arise against, any member of the board or its
445 employees or agents for any action taken by them in the
446 performance of their powers and duties under this section.
447 (f) The board shall develop and adopt bylaws and other
448 corporate procedures as necessary for the operation of the
449 corporation and carrying out the purposes of this section. The
450 bylaws shall:
451 1. Specify procedures for selection of officers and
452 qualifications for reappointment, provided that no board member
453 shall serve more than 9 consecutive years.
454 2. Require an annual membership meeting that provides an
455 opportunity for input and interaction with individual
456 participants in the program.
457 3. Specify policies and procedures regarding conflicts of
458 interest, including the provisions of part III of chapter 112,
459 which prohibit a member from participating in any decision that
460 would inure to the benefit of the member or the organization
461 that employs the member. The policies and procedures shall also
462 require public disclosure of the interest that prevents the
463 member from participating in a decision on a particular matter.
464 (g) The corporation may exercise all powers granted to it
465 under chapter 617 necessary to carry out the purposes of this
466 section, including, but not limited to, the power to receive and
467 accept grants, loans, or advances of funds from any public or
468 private agency and to receive and accept from any source
469 contributions of money, property, labor, or any other thing of
470 value to be held, used, and applied for the purposes of this
471 section.
472 (h) The corporation may establish technical advisory panels
473 consisting of interested parties, including consumers, health
474 care providers, individuals with expertise in insurance
475 regulation, and insurers.
476 (i) The corporation shall:
477 1. Determine eligibility of employers, vendors,
478 individuals, and agents in accordance with subsection (4).
479 2. Establish procedures necessary for the operation of the
480 program, including, but not limited to, procedures for
481 application, enrollment, risk assessment, risk adjustment, plan
482 administration, performance monitoring, and consumer education.
483 3. Arrange for collection of contributions from
484 participating employers and individuals.
485 4. Arrange for payment of premiums and other appropriate
486 disbursements based on the selections of products and services
487 by the individual participants.
488 5. Establish criteria for disenrollment of participating
489 individuals based on failure to pay the individual’s share of
490 any contribution required to maintain enrollment in selected
491 products.
492 6. Establish criteria for exclusion of vendors pursuant to
493 paragraph (4)(d).
494 7. Develop and implement a plan for promoting public
495 awareness of and participation in the program.
496 8. Secure staff and consultant services necessary to the
497 operation of the program.
498 9. Establish policies and procedures regarding
499 participation in the program for individuals, vendors, health
500 insurance agents, and employers.
501 10. Provide for the operation of a toll-free hotline to
502 respond to requests for assistance.
503 11. Provide for initial, open, and special enrollment
504 periods not to exceed 60 days.
505 12. Establish options for employer participation which may
506 conform with common insurance practices.
507 10. Develop a plan, in coordination with the Department of
508 Revenue, to establish tax credits or refunds for employers that
509 participate in the program. The corporation shall submit the
510 plan to the Governor, the President of the Senate, and the
511 Speaker of the House of Representatives by January 1, 2009.
512 (12) REPORT.—Beginning in the 2009-2010 fiscal year, submit
513 by February 1 an annual report to the Governor, the President of
514 the Senate, and the Speaker of the House of Representatives
515 documenting the corporation’s activities in compliance with the
516 duties delineated in this section.
517 (13) PROGRAM INTEGRITY.—To ensure program integrity and to
518 safeguard the financial transactions made under the auspices of
519 the program, the corporation is authorized to establish
520 qualifying criteria and certification procedures for vendors,
521 require performance bonds or other guarantees of ability to
522 complete contractual obligations, monitor the performance of
523 vendors, and enforce the agreements of the program through
524 financial penalty or disqualification from the program.
525 Section 2. Section 409.821, Florida Statutes, is amended to
526 read:
527 409.821 Florida Kidcare program public records exemption.—
528 (1) Personal identifying information of a Florida Kidcare
529 program applicant or enrollee, as defined in s. 409.811, held by
530 the Agency for Health Care Administration, the Department of
531 Children and Family Services, the Department of Health, or the
532 Florida Healthy Kids Corporation is confidential and exempt from
533 s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
534 (2)(a) Upon request, such information shall be disclosed
535 to:
536 1. Another governmental entity in the performance of its
537 official duties and responsibilities;
538 2. The Department of Revenue for purposes of administering
539 the state Title IV-D program; or
540 3. The Florida Health Choices, Inc., for the purpose of
541 administering the program authorized pursuant to s. 408.910; or
542 4.3. Any person who has the written consent of the program
543 applicant.
544 (b) This section does not prohibit an enrollee’s legal
545 guardian from obtaining confirmation of coverage, dates of
546 coverage, the name of the enrollee’s health plan, and the amount
547 of premium being paid.
548 (3) This exemption applies to any information identifying a
549 Florida Kidcare program applicant or enrollee held by the Agency
550 for Health Care Administration, the Department of Children and
551 Family Services, the Department of Health, or the Florida
552 Healthy Kids Corporation before, on, or after the effective date
553 of this exemption.
554 (4) A knowing and willful violation of this section is a
555 misdemeanor of the second degree, punishable as provided in s.
556 775.082 or s. 775.083.
557 Section 3. Subsection (41) of section 409.912, Florida
558 Statutes, is amended to read:
559 409.912 Cost-effective purchasing of health care.—The
560 agency shall purchase goods and services for Medicaid recipients
561 in the most cost-effective manner consistent with the delivery
562 of quality medical care. To ensure that medical services are
563 effectively utilized, the agency may, in any case, require a
564 confirmation or second physician’s opinion of the correct
565 diagnosis for purposes of authorizing future services under the
566 Medicaid program. This section does not restrict access to
567 emergency services or poststabilization care services as defined
568 in 42 C.F.R. part 438.114. Such confirmation or second opinion
569 shall be rendered in a manner approved by the agency. The agency
570 shall maximize the use of prepaid per capita and prepaid
571 aggregate fixed-sum basis services when appropriate and other
572 alternative service delivery and reimbursement methodologies,
573 including competitive bidding pursuant to s. 287.057, designed
574 to facilitate the cost-effective purchase of a case-managed
575 continuum of care. The agency shall also require providers to
576 minimize the exposure of recipients to the need for acute
577 inpatient, custodial, and other institutional care and the
578 inappropriate or unnecessary use of high-cost services. The
579 agency shall contract with a vendor to monitor and evaluate the
580 clinical practice patterns of providers in order to identify
581 trends that are outside the normal practice patterns of a
582 provider’s professional peers or the national guidelines of a
583 provider’s professional association. The vendor must be able to
584 provide information and counseling to a provider whose practice
585 patterns are outside the norms, in consultation with the agency,
586 to improve patient care and reduce inappropriate utilization.
587 The agency may mandate prior authorization, drug therapy
588 management, or disease management participation for certain
589 populations of Medicaid beneficiaries, certain drug classes, or
590 particular drugs to prevent fraud, abuse, overuse, and possible
591 dangerous drug interactions. The Pharmaceutical and Therapeutics
592 Committee shall make recommendations to the agency on drugs for
593 which prior authorization is required. The agency shall inform
594 the Pharmaceutical and Therapeutics Committee of its decisions
595 regarding drugs subject to prior authorization. The agency is
596 authorized to limit the entities it contracts with or enrolls as
597 Medicaid providers by developing a provider network through
598 provider credentialing. The agency may competitively bid single
599 source-provider contracts if procurement of goods or services
600 results in demonstrated cost savings to the state without
601 limiting access to care. The agency may limit its network based
602 on the assessment of beneficiary access to care, provider
603 availability, provider quality standards, time and distance
604 standards for access to care, the cultural competence of the
605 provider network, demographic characteristics of Medicaid
606 beneficiaries, practice and provider-to-beneficiary standards,
607 appointment wait times, beneficiary use of services, provider
608 turnover, provider profiling, provider licensure history,
609 previous program integrity investigations and findings, peer
610 review, provider Medicaid policy and billing compliance records,
611 clinical and medical record audits, and other factors. Providers
612 shall not be entitled to enrollment in the Medicaid provider
613 network. The agency shall determine instances in which allowing
614 Medicaid beneficiaries to purchase durable medical equipment and
615 other goods is less expensive to the Medicaid program than long
616 term rental of the equipment or goods. The agency may establish
617 rules to facilitate purchases in lieu of long-term rentals in
618 order to protect against fraud and abuse in the Medicaid program
619 as defined in s. 409.913. The agency may seek federal waivers
620 necessary to administer these policies.
621 (41) The agency shall establish provide for the development
622 of a demonstration project by establishment in Miami-Dade County
623 of a long-term-care facility and a psychiatric facility licensed
624 pursuant to chapter 395 to improve access to health care for a
625 predominantly minority, medically underserved, and medically
626 complex population and to evaluate alternatives to nursing home
627 care and general acute care for such population. Such project is
628 to be located in a health care condominium and collocated
629 colocated with licensed facilities providing a continuum of
630 care. These projects are The establishment of this project is
631 not subject to the provisions of s. 408.036 or s. 408.039.
632 Section 4. This act shall take effect July 1, 2011.