Florida Senate - 2014                                     SB 340
       By Senator Flores
       37-00179-14                                            2014340__
    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; authorizing the agency to seek any
   11         necessary revisions to the state plan or federal
   12         waivers; providing an effective date.
   14  Be It Enacted by the Legislature of the State of Florida:
   16         Section 1. Subsection (41) of section 409.912, Florida
   17  Statutes, is amended to read:
   18         409.912 Cost-effective purchasing of health care.—The
   19  agency shall purchase goods and services for Medicaid recipients
   20  in the most cost-effective manner consistent with the delivery
   21  of quality medical care. To ensure that medical services are
   22  effectively utilized, the agency may, in any case, require a
   23  confirmation or second physician’s opinion of the correct
   24  diagnosis for purposes of authorizing future services under the
   25  Medicaid program. This section does not restrict access to
   26  emergency services or poststabilization care services as defined
   27  in 42 C.F.R. part 438.114. Such confirmation or second opinion
   28  shall be rendered in a manner approved by the agency. The agency
   29  shall maximize the use of prepaid per capita and prepaid
   30  aggregate fixed-sum basis services when appropriate and other
   31  alternative service delivery and reimbursement methodologies,
   32  including competitive bidding pursuant to s. 287.057, designed
   33  to facilitate the cost-effective purchase of a case-managed
   34  continuum of care. The agency shall also require providers to
   35  minimize the exposure of recipients to the need for acute
   36  inpatient, custodial, and other institutional care and the
   37  inappropriate or unnecessary use of high-cost services. The
   38  agency shall contract with a vendor to monitor and evaluate the
   39  clinical practice patterns of providers in order to identify
   40  trends that are outside the normal practice patterns of a
   41  provider’s professional peers or the national guidelines of a
   42  provider’s professional association. The vendor must be able to
   43  provide information and counseling to a provider whose practice
   44  patterns are outside the norms, in consultation with the agency,
   45  to improve patient care and reduce inappropriate utilization.
   46  The agency may mandate prior authorization, drug therapy
   47  management, or disease management participation for certain
   48  populations of Medicaid beneficiaries, certain drug classes, or
   49  particular drugs to prevent fraud, abuse, overuse, and possible
   50  dangerous drug interactions. The Pharmaceutical and Therapeutics
   51  Committee shall make recommendations to the agency on drugs for
   52  which prior authorization is required. The agency shall inform
   53  the Pharmaceutical and Therapeutics Committee of its decisions
   54  regarding drugs subject to prior authorization. The agency is
   55  authorized to limit the entities it contracts with or enrolls as
   56  Medicaid providers by developing a provider network through
   57  provider credentialing. The agency may competitively bid single
   58  source-provider contracts if procurement of goods or services
   59  results in demonstrated cost savings to the state without
   60  limiting access to care. The agency may limit its network based
   61  on the assessment of beneficiary access to care, provider
   62  availability, provider quality standards, time and distance
   63  standards for access to care, the cultural competence of the
   64  provider network, demographic characteristics of Medicaid
   65  beneficiaries, practice and provider-to-beneficiary standards,
   66  appointment wait times, beneficiary use of services, provider
   67  turnover, provider profiling, provider licensure history,
   68  previous program integrity investigations and findings, peer
   69  review, provider Medicaid policy and billing compliance records,
   70  clinical and medical record audits, and other factors. Providers
   71  are not entitled to enrollment in the Medicaid provider network.
   72  The agency shall determine instances in which allowing Medicaid
   73  beneficiaries to purchase durable medical equipment and other
   74  goods is less expensive to the Medicaid program than long-term
   75  rental of the equipment or goods. The agency may establish rules
   76  to facilitate purchases in lieu of long-term rentals in order to
   77  protect against fraud and abuse in the Medicaid program as
   78  defined in s. 409.913. The agency may seek federal waivers
   79  necessary to administer these policies.
   80         (41)(a) Notwithstanding s. 409.961, the agency shall
   81  contract on a prepaid or fixed-sum basis with appropriately
   82  licensed prepaid dental health plans to provide dental services.
   83  This paragraph expires October 1, 2017 2014.
   84         (b) Notwithstanding paragraph (a), the agency may provide a
   85  Medicaid prepaid dental health program in Miami-Dade County.
   86         (b) Notwithstanding paragraph (a) and for the 2012-2013
   87  fiscal year only, the agency is authorized to provide a Medicaid
   88  prepaid dental health program in Miami-Dade County. For all
   89  other counties, the agency may not limit dental services to
   90  prepaid plans and must allow qualified dental providers to
   91  provide dental services under Medicaid on a fee-for-service
   92  reimbursement methodology. The agency may seek any necessary
   93  revisions or amendments to the state plan or federal waivers in
   94  order to implement this paragraph. The agency shall terminate
   95  existing contracts as needed to implement this paragraph. This
   96  paragraph expires July 1, 2013.
   97         (c) The agency shall provide a report by January 15 of each
   98  year to the Governor, the President of the Senate, and the
   99  Speaker of the House of Representatives which compares the
  100  combined annual benefits utilization and encounter data reported
  101  by all contractors, along with the agency’s findings with
  102  respect to projected and budgeted annual program costs, the
  103  extent to which each contracting entity is complying with all
  104  contract terms and conditions, the effect that each entity’s
  105  operation is having on access to care for Medicaid recipients in
  106  the contractor’s service area, and the statistical trends
  107  associated with indicators of good oral health among all
  108  recipients served in comparison with the state’s population as a
  109  whole.
  110         (d) The agency may seek any necessary revisions or
  111  amendments to the state plan or federal waivers in order to
  112  implement this subsection.
  113         Section 2. This act shall take effect July 1, 2014.