Florida Senate - 2013 CS for SB 896
By the Committee on Health Policy; and Senators Garcia and
Flores
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.
11
12 Be It Enacted by the Legislature of the State of Florida:
13
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.