Florida Senate - 2013                              CS for SB 896
       By the Committee on Health Policy; and Senators Garcia and
       588-02413-13                                           2013896c1
    1                        A bill to be entitled                      
    2         An act relating to prepaid dental plans; amending s.
    3         409.912, F.S.; postponing the scheduled repeal of a
    4         provision requiring the Agency for Health Care
    5         Administration to contract with dental plans for
    6         dental services on a prepaid or fixed-sum basis;
    7         authorizing the agency to provide a prepaid dental
    8         health program in Miami-Dade County on a permanent
    9         basis; requiring an annual report to the Governor and
   10         Legislature; providing an effective date.
   12  Be It Enacted by the Legislature of the State of Florida:
   14         Section 1. Subsection (41) of section 409.912, Florida
   15  Statutes, is amended to read:
   16         409.912 Cost-effective purchasing of health care.—The
   17  agency shall purchase goods and services for Medicaid recipients
   18  in the most cost-effective manner consistent with the delivery
   19  of quality medical care. To ensure that medical services are
   20  effectively utilized, the agency may, in any case, require a
   21  confirmation or second physician’s opinion of the correct
   22  diagnosis for purposes of authorizing future services under the
   23  Medicaid program. This section does not restrict access to
   24  emergency services or poststabilization care services as defined
   25  in 42 C.F.R. part 438.114. Such confirmation or second opinion
   26  shall be rendered in a manner approved by the agency. The agency
   27  shall maximize the use of prepaid per capita and prepaid
   28  aggregate fixed-sum basis services when appropriate and other
   29  alternative service delivery and reimbursement methodologies,
   30  including competitive bidding pursuant to s. 287.057, designed
   31  to facilitate the cost-effective purchase of a case-managed
   32  continuum of care. The agency shall also require providers to
   33  minimize the exposure of recipients to the need for acute
   34  inpatient, custodial, and other institutional care and the
   35  inappropriate or unnecessary use of high-cost services. The
   36  agency shall contract with a vendor to monitor and evaluate the
   37  clinical practice patterns of providers in order to identify
   38  trends that are outside the normal practice patterns of a
   39  provider’s professional peers or the national guidelines of a
   40  provider’s professional association. The vendor must be able to
   41  provide information and counseling to a provider whose practice
   42  patterns are outside the norms, in consultation with the agency,
   43  to improve patient care and reduce inappropriate utilization.
   44  The agency may mandate prior authorization, drug therapy
   45  management, or disease management participation for certain
   46  populations of Medicaid beneficiaries, certain drug classes, or
   47  particular drugs to prevent fraud, abuse, overuse, and possible
   48  dangerous drug interactions. The Pharmaceutical and Therapeutics
   49  Committee shall make recommendations to the agency on drugs for
   50  which prior authorization is required. The agency shall inform
   51  the Pharmaceutical and Therapeutics Committee of its decisions
   52  regarding drugs subject to prior authorization. The agency is
   53  authorized to limit the entities it contracts with or enrolls as
   54  Medicaid providers by developing a provider network through
   55  provider credentialing. The agency may competitively bid single
   56  source-provider contracts if procurement of goods or services
   57  results in demonstrated cost savings to the state without
   58  limiting access to care. The agency may limit its network based
   59  on the assessment of beneficiary access to care, provider
   60  availability, provider quality standards, time and distance
   61  standards for access to care, the cultural competence of the
   62  provider network, demographic characteristics of Medicaid
   63  beneficiaries, practice and provider-to-beneficiary standards,
   64  appointment wait times, beneficiary use of services, provider
   65  turnover, provider profiling, provider licensure history,
   66  previous program integrity investigations and findings, peer
   67  review, provider Medicaid policy and billing compliance records,
   68  clinical and medical record audits, and other factors. Providers
   69  are not entitled to enrollment in the Medicaid provider network.
   70  The agency shall determine instances in which allowing Medicaid
   71  beneficiaries to purchase durable medical equipment and other
   72  goods is less expensive to the Medicaid program than long-term
   73  rental of the equipment or goods. The agency may establish rules
   74  to facilitate purchases in lieu of long-term rentals in order to
   75  protect against fraud and abuse in the Medicaid program as
   76  defined in s. 409.913. The agency may seek federal waivers
   77  necessary to administer these policies.
   78         (41)(a) The agency shall contract on a prepaid or fixed-sum
   79  basis with appropriately licensed prepaid dental health plans to
   80  provide dental services. This paragraph expires October 1, 2017
   81  2014.
   82         (b) Notwithstanding paragraph (a) and for the 2012-2013
   83  fiscal year only, the agency may is authorized to provide a
   84  Medicaid prepaid dental health program in Miami-Dade County. The
   85  agency shall provide an annual report by January 15 to the
   86  Governor, the President of the Senate, and the Speaker of the
   87  House of Representatives which compares the combined reported
   88  annual benefits utilization and encounter data from all
   89  contractors, along with the agency’s findings as to projected
   90  and budgeted annual program costs, the extent to which each
   91  contracting entity is complying with all contract terms and
   92  conditions, the effect that each entity’s operation is having on
   93  access to care for Medicaid recipients in the contractor’s
   94  service area, and the statistical trends associated with
   95  indicators of good oral health among all recipients served in
   96  comparison with the state’s population as a whole. For all other
   97  counties, the agency may not limit dental services to prepaid
   98  plans and must allow qualified dental providers to provide
   99  dental services under Medicaid on a fee-for-service
  100  reimbursement methodology. The agency may seek any necessary
  101  revisions or amendments to the state plan or federal waivers in
  102  order to implement this paragraph. The agency shall terminate
  103  existing contracts as needed to implement this paragraph. This
  104  paragraph expires July 1, 2013.
  105         Section 2. This act shall take effect June 30, 2013.