HB 1133

1
A bill to be entitled
2An act relating to Medicaid; amending s. 409.912, F.S.;
3authorizing the Agency for Health Care Administration, in
4collaboration with the Department of Health, to develop a
5home and community-based services Medicaid waiver program
6to serve children diagnosed with Trisomy 18, subject to
7federal waiver approval; providing rulemaking authority;
8providing an effective date.
9
10Be It Enacted by the Legislature of the State of Florida:
11
12     Section 1.  Subsection (54) is added to section 409.912,
13Florida Statutes, to read:
14     409.912  Cost-effective purchasing of health care.-The
15agency shall purchase goods and services for Medicaid recipients
16in the most cost-effective manner consistent with the delivery
17of quality medical care. To ensure that medical services are
18effectively utilized, the agency may, in any case, require a
19confirmation or second physician's opinion of the correct
20diagnosis for purposes of authorizing future services under the
21Medicaid program. This section does not restrict access to
22emergency services or poststabilization care services as defined
23in 42 C.F.R. part 438.114. Such confirmation or second opinion
24shall be rendered in a manner approved by the agency. The agency
25shall maximize the use of prepaid per capita and prepaid
26aggregate fixed-sum basis services when appropriate and other
27alternative service delivery and reimbursement methodologies,
28including competitive bidding pursuant to s. 287.057, designed
29to facilitate the cost-effective purchase of a case-managed
30continuum of care. The agency shall also require providers to
31minimize the exposure of recipients to the need for acute
32inpatient, custodial, and other institutional care and the
33inappropriate or unnecessary use of high-cost services. The
34agency shall contract with a vendor to monitor and evaluate the
35clinical practice patterns of providers in order to identify
36trends that are outside the normal practice patterns of a
37provider's professional peers or the national guidelines of a
38provider's professional association. The vendor must be able to
39provide information and counseling to a provider whose practice
40patterns are outside the norms, in consultation with the agency,
41to improve patient care and reduce inappropriate utilization.
42The agency may mandate prior authorization, drug therapy
43management, or disease management participation for certain
44populations of Medicaid beneficiaries, certain drug classes, or
45particular drugs to prevent fraud, abuse, overuse, and possible
46dangerous drug interactions. The Pharmaceutical and Therapeutics
47Committee shall make recommendations to the agency on drugs for
48which prior authorization is required. The agency shall inform
49the Pharmaceutical and Therapeutics Committee of its decisions
50regarding drugs subject to prior authorization. The agency is
51authorized to limit the entities it contracts with or enrolls as
52Medicaid providers by developing a provider network through
53provider credentialing. The agency may competitively bid single-
54source-provider contracts if procurement of goods or services
55results in demonstrated cost savings to the state without
56limiting access to care. The agency may limit its network based
57on the assessment of beneficiary access to care, provider
58availability, provider quality standards, time and distance
59standards for access to care, the cultural competence of the
60provider network, demographic characteristics of Medicaid
61beneficiaries, practice and provider-to-beneficiary standards,
62appointment wait times, beneficiary use of services, provider
63turnover, provider profiling, provider licensure history,
64previous program integrity investigations and findings, peer
65review, provider Medicaid policy and billing compliance records,
66clinical and medical record audits, and other factors. Providers
67shall not be entitled to enrollment in the Medicaid provider
68network. The agency shall determine instances in which allowing
69Medicaid beneficiaries to purchase durable medical equipment and
70other goods is less expensive to the Medicaid program than long-
71term rental of the equipment or goods. The agency may establish
72rules to facilitate purchases in lieu of long-term rentals in
73order to protect against fraud and abuse in the Medicaid program
74as defined in s. 409.913. The agency may seek federal waivers
75necessary to administer these policies.
76     (54)  The agency shall work with the Department of Health
77to develop a home and community-based services Medicaid waiver
78program to serve children diagnosed with Trisomy 18, also known
79as Edwards syndrome, a rare genetic disorder that is
80characterized by heart abnormalities, kidney dysfunction, and
81other internal disorders. The agency shall implement the program
82subject to federal waiver approval, the availability of funds,
83and any limitations provided in the General Appropriations Act.
84The agency may adopt rules to implement this subsection.
85     Section 2.  This act shall take effect July 1, 2011.


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