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.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
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.