((LATE FILED FOR: APRIL 28 SPECIAL ORDER ))	Amendment
Bill No. CS/CS/CS/SB 1986

Amendment No. 092577

CHAMBER ACTION
Senate		House
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1	Representative Adkins offered the following:
2
3	Amendment
4	Remove lines 1275-1552 and insert:
5	treatment and not in excess of the patient's needs, except for
6	services provided under s. 394.4574(2)(c) and (3). The agency
7	shall conduct reviews of provider exceptions to peer group norms
8	and shall, using statistical methodologies, provider profiling,
9	and analysis of billing patterns, detect and investigate
10	abnormal or unusual increases in billing or payment of claims
11	for Medicaid services and medically unnecessary provision of
12	services. Providers that demonstrate a pattern of submitting
13	claims for medically unnecessary services shall be referred to
14	the Medicaid program integrity unit for investigation. In its
15	annual report, required in s. 409.913, the agency shall report
16	on its efforts to control overutilization as described in this
17	paragraph.
18	(b)  The agency shall develop a procedure for determining
19	whether health care providers and service vendors can provide
20	the Medicaid program using a business case that demonstrates
21	whether a particular good or service can offset the cost of
22	providing the good or service in an alternative setting or
23	through other means and therefore should receive a higher
24	reimbursement. The business case must include, but need not be
25	limited to:
26	1.  A detailed description of the good or service to be
27	provided, a description and analysis of the agency's current
28	performance of the service, and a rationale documenting how
29	providing the service in an alternative setting would be in the
30	best interest of the state, the agency, and its clients.
31	2.  A cost-benefit analysis documenting the estimated
32	specific direct and indirect costs, savings, performance
33	improvements, risks, and qualitative and quantitative benefits
34	involved in or resulting from providing the service. The cost-
35	benefit analysis must include a detailed plan and timeline
36	identifying all actions that must be implemented to realize
37	expected benefits. The Secretary of Health Care Administration
38	shall verify that all costs, savings, and benefits are valid and
39	achievable.
40	(c)  If the agency determines that the increased
41	reimbursement is cost-effective, the agency shall recommend a
42	change in the reimbursement schedule for that particular good or
43	service. If, within 12 months after implementing any rate change
44	under this procedure, the agency determines that costs were not
45	offset by the increased reimbursement schedule, the agency may
46	revert to the former reimbursement schedule for the particular
47	good or service.
48	(17)  An entity contracting on a prepaid or fixed-sum basis
49	shall meet the, in addition to meeting any applicable statutory
50	surplus requirements of s. 641.225, also maintain at all times
51	in the form of cash, investments that mature in less than 180
52	days allowable as admitted assets by the Office of Insurance
53	Regulation, and restricted funds or deposits controlled by the
54	agency or the Office of Insurance Regulation, a surplus amount
55	equal to one-and-one-half times the entity's monthly Medicaid
56	prepaid revenues. As used in this subsection, the term "surplus"
57	means the entity's total assets minus total liabilities. If an
58	entity's surplus falls below an amount equal to the surplus
59	requirements of s. 641.225 one-and-one-half times the entity's
60	monthly Medicaid prepaid revenues, the agency shall prohibit the
61	entity from engaging in marketing and preenrollment activities,
62	shall cease to process new enrollments, and may shall not renew
63	the entity's contract until the required balance is achieved.
64	The requirements of this subsection do not apply:
65	(a)  Where a public entity agrees to fund any deficit
66	incurred by the contracting entity; or
67	(b)  Where the entity's performance and obligations are
68	guaranteed in writing by a guaranteeing organization which:
69	1.  Has been in operation for at least 5 years and has
70	assets in excess of $50 million; or
71	2.  Submits a written guarantee acceptable to the agency
72	which is irrevocable during the term of the contracting entity's
73	contract with the agency and, upon termination of the contract,
74	until the agency receives proof of satisfaction of all
75	outstanding obligations incurred under the contract.
76	Section 17.  Section 409.91207, Florida Statutes, is
77	created to read:
78	409.91207  Medical Home Pilot Project.--
79	(1)  The agency shall develop a plan to implement a medical
80	home pilot project that utilizes primary care case management
81	enhanced by medical home networks to provide coordinated and
82	cost-effective care that is reimbursed on a fee-for-service
83	basis and to compare the performance of the medical home
84	networks with other existing Medicaid managed care models. The
85	agency is authorized to seek a federal Medicaid waiver or an
86	amendment to any existing Medicaid waiver, except for the
87	current 1115 Medicaid waiver authorized in s. 409.91211, as
88	needed, to develop the pilot project created in this section but
89	must obtain approval of the Legislature prior to implementing
90	the pilot project.
91	(2)  Each medical home network shall:
92	(a)  Provide Medicaid recipients primary care, coordinated
93	services to control chronic illness, pharmacy services,
94	specialty physician services, and hospital outpatient and
95	inpatient services.
96	(b) Coordinate with other health care providers, as
97	necessary, to ensure that Medicaid recipients receive efficient
98	and effective access to other needed medical services,
99	consistent with the scope of services provided to Medipass
100	recipients.
101	(c)  Consist of primary care physicians, federally
102	qualified health centers, clinics affiliated with Florida
103	medical schools or teaching hospitals, programs serving children
104	with special health care needs, medical school faculty,
105	statutory teaching hospitals, and other hospitals that agree to
106	participate in the network. A managed care organization is
107	eligible to be designated as a medical home network if it
108	documents policies and procedures consistent with subsection
109	(3).
110	(3)  The medical home pilot project developed by the agency
111	must be designed to modify the processes and patterns of health
112	care service delivery in the Medicaid program by requiring a
113	medical home network to:
114	(a) Assign a personal medical provider to lead an
115	interdisciplinary team of professionals who share the
116	responsibility for ongoing care to a specific panel of patients.
117	(b) Require the personal medical provider to identify the
118	patient's health care needs and respond to those needs either
119	directly or through arrangements with other qualified providers.
120	(c) Coordinate or integrate care across all parts of the
121	health care delivery system.
122	(d) Integrate information technology into the health care
123	delivery system to enhance clinical performance and monitor
124	patient outcomes.
125	(4)  The agency shall have the following duties, and
126	responsibilities with respect to the development of the medical
127	home pilot project:
128	(a)  To develop and recommend a medical home pilot project
129	in at least two geographic regions in the state that will
130	facilitate access to specialty services in the state's medical
131	schools and teaching hospitals.
132	(b)  To develop and recommend funding strategies that
133	maximize available state and federal funds, including:
134	1.  Enhanced primary care case management fees to
135	participating federally qualified health centers and primary
136	care clinics owned or operated by a medical school or teaching
137	hospital.
138	2.  Enhanced payments to participating medical schools
139	through the supplemental physician payment program using
140	certified funds.
141	3.  Reimbursement for facility costs, in addition to
142	medical services, for participating outpatient primary or
143	specialty clinics.
144	4.  Supplemental Medicaid payments through the low-income
145	pool and exempt fee-for-service rates for participating
146	hospitals.
147	5.  Enhanced capitation rates for managed care
148	organizations designated as medical home networks to reflect
149	enhanced fee-for-service payments to medical home network
150	providers.
151	(c)  To develop and recommend criteria to designate medical
152	home networks as eligible to participate in the pilot program
153	and recommend incentives for medical home networks to
154	participate in the medical home pilot project, including bonus
155	payments and shared saving arrangements.
156	(d)  To develop a comprehensive fiscal estimate of the
157	medical home pilot project that includes, but is not limited to,
158	anticipated savings to the Medicaid program and any anticipated
159	administrative costs.
160	(e)  To develop and recommend which medical services the
161	medical home network would be responsible for providing to
162	enrolled Medicaid recipients.
163	(f)  To develop and recommend methodologies to measure the
164	performance of the medical home pilot project including patient
165	outcomes, cost-effectiveness, provider participation, recipient
166	satisfaction, and accountability to ensure the quality of the
167	medical care provided to Medicaid recipients enrolled in the
168	pilot.
169	(g)  To recommend policies and procedures for the medical
170	home pilot project administration including, but not limited to:
171	an implementation timeline, the Medicaid recipient enrollment
172	process, recruitment and enrollment of Medicaid providers, and
173	the reimbursement methodologies for participating Medicaid
174	providers.
175	(h)  To determine and recommend methods to evaluate the
176	medical home pilot project including but not limited to the
177	comparison of the Medicaid fee-for service system, Medipass
178	system, and other Medicaid managed care programs.
179	(i)  To develop and recommend standards and designation
180	requirements for a medical home network that include, but are
181	not limited to: medical care provided by the network, referral
182	arrangements, medical record requirements, health information
183	technology standards, follow-up care processes, and data
184	collection requirements.
185	(5)  The Secretary of Health Care Administration shall
186	appoint a task force by August 1, 2009, to assist the agency in
187	the development and implementation of the medical home pilot
188	project. The task force must include, but is not limited to,
189	representatives of providers who could potentially participate
190	in a medical home network, Medicaid recipients, and existing
191	Medipass and managed care providers. Members of the task force
192	shall serve without compensation but are entitled to
193	reimbursement for per diem and travel expenses as provided in s.
194	112.061.
195	(6)  The agency shall submit an implementation plan for the
196	medical home pilot project authorized in this section to the
197	Speaker of the House of Representatives, the President of the
198	Senate, and the Governor by February 1, 2010. The implementation
199	plan must include any approved waivers, waiver applications, or
200	state plan amendments necessary to implement the medical home
201	pilot project.
202	(a)  The agency shall post any waiver applications, or
203	waiver amendments, authorized under this section on its Internet
204	website 15 days before submitting the applications to the United
205	States Centers for Medicare and Medicaid Services.
206	(b)  The implementation of the medical home pilot project,
207	including any Medicaid waivers authorized in this section, is
208	contingent upon review and approval by the Legislature.
209	(c)  Upon legislative approval to implement the medical
210	home pilot project, the agency may initiate the adoption of
211	administrative rules to implement and administer the medical
212	home pilot project created in this section.
213	Section 18.  Subsections (2), (7), (11), (13), (14), (15),
214	(24), (25), (27), (30), (31), and (36) of section 409.913,
215	Florida Statutes, are amended, and subsections (37) and (38) are
216	added to that section, to read:
217	409.913  Oversight of the integrity of the Medicaid
218	program.--The agency shall operate a program to oversee the
219	activities of Florida Medicaid recipients, and providers and
220	their representatives, to ensure that fraudulent and abusive
221	behavior and neglect of recipients occur to the minimum extent
222	possible, and to recover overpayments and impose sanctions as
223	appropriate. Beginning January 1, 2003, and each year
224	thereafter, the agency and the Medicaid Fraud Control Unit of
225	the Department of Legal Affairs shall submit a joint report to
226	the Legislature documenting the effectiveness of the state's
227	efforts to control Medicaid fraud and abuse and to recover
228	Medicaid overpayments during the previous fiscal year. The
229	report must describe the number of cases opened and investigated
230	each year; the sources of the cases opened; the disposition of
231	the cases closed each year; the amount of overpayments alleged
232	in preliminary and final audit letters; the number and amount of
233	fines or penalties imposed; any reductions in overpayment
234	amounts negotiated in settlement agreements or by other means;
235	the amount of final agency determinations of overpayments; the
236	amount deducted from federal claiming as a result of
237	overpayments; the amount of overpayments recovered each year;
238	the amount of cost of investigation recovered each year; the
239	average length of time to collect from the time the case was
240	opened until the overpayment is paid in full; the amount
241	determined as uncollectible and the portion of the uncollectible
242	amount subsequently reclaimed from the Federal Government; the
243	number of providers, by type, that are terminated from
244	participation in the Medicaid program as a result of fraud and
245	abuse; and all costs associated with discovering and prosecuting
246	cases of Medicaid overpayments and making recoveries in such
247	cases. The report must also document actions taken to prevent
248	overpayments and the number of providers prevented from
249	enrolling in or reenrolling in the Medicaid program as a result
250	of documented Medicaid fraud and abuse and must include policy
251	recommendations recommend changes necessary to prevent or
252	recover overpayments and changes necessary to prevent and detect
253	Medicaid fraud. All policy recommendations in the report must
254	include a detailed fiscal analysis, including, but not limited
255	to, implementation costs, estimated savings to the Medicaid
256	program, and the return on investment. The agency must submit
257	the policy recommendations and fiscal analyses in the report to
258	the appropriate estimating conference, pursuant to s. 216.137,
259	by February 15 of each year. The agency and the Medicaid Fraud
260	Control Unit of the Department of Legal Affairs each must
261	include detailed unit-specific performance standards,
262	benchmarks, and metrics in the report, including projected cost
263	savings to the state Medicaid program during the following
264	fiscal year.
265	(2)  The agency shall conduct, or cause to be conducted by
266	contract or otherwise, reviews, investigations, analyses,
267	audits, or any combination thereof, to determine possible fraud,
268	abuse, overpayment, or recipient neglect in the Medicaid program
269	and shall report the findings of any overpayments in audit
270	reports as appropriate. At least 5 percent of all audits shall
271	be conducted on a random basis. As part of its ongoing fraud
272	detection activities, the agency shall identify and monitor, by
273	contract or otherwise, patterns of overutilization of Medicaid
274	services based on state averages. The agency shall track
275	Medicaid provider prescription and billing patterns and evaluate
276	them against Medicaid medical necessity criteria and coverage
277	and limitation guidelines adopted by rule. Medical necessity
278	determination requires that service be consistent with symptoms
279	or confirmed diagnosis of illness or injury under treatment and
280	not in excess of the patient's needs. The agency shall conduct
281	reviews of provider exceptions to peer group norms and shall,
282	using statistical methodologies, provider profiling, and
283	analysis of billing patterns, detect and investigate abnormal or
284	unusual increases in billing or payment of claims for Medicaid
285	services and medically unnecessary provision of services, except
286	for services provided under s. 394.4574(2)(c) and (3).

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