| 1 | The Health Care Appropriations Committee recommends the |
| 2 | following: |
| 3 |
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| 4 | Council/Committee Substitute |
| 5 | Remove the entire bill and insert: |
| 6 | A bill to be entitled |
| 7 | An act relating to developmental disabilities; amending s. |
| 8 | 409.912, F.S.; requiring the Agency for Health Care |
| 9 | Administration to develop a waiver program to serve |
| 10 | children and adults with specified disorders; requiring |
| 11 | the agency to seek federal approval and implement the |
| 12 | approved waiver in the General Appropriations Act, subject |
| 13 | to certain limitations; providing an effective date. |
| 14 |
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| 15 | Be It Enacted by the Legislature of the State of Florida: |
| 16 |
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| 17 | Section 1. Subsection (51) of section 409.912, Florida |
| 18 | Statutes, is amended to read: |
| 19 | 409.912 Cost-effective purchasing of health care.--The |
| 20 | agency shall purchase goods and services for Medicaid recipients |
| 21 | in the most cost-effective manner consistent with the delivery |
| 22 | of quality medical care. To ensure that medical services are |
| 23 | effectively utilized, the agency may, in any case, require a |
| 24 | confirmation or second physician's opinion of the correct |
| 25 | diagnosis for purposes of authorizing future services under the |
| 26 | Medicaid program. This section does not restrict access to |
| 27 | emergency services or poststabilization care services as defined |
| 28 | in 42 C.F.R. part 438.114. Such confirmation or second opinion |
| 29 | shall be rendered in a manner approved by the agency. The agency |
| 30 | shall maximize the use of prepaid per capita and prepaid |
| 31 | aggregate fixed-sum basis services when appropriate and other |
| 32 | alternative service delivery and reimbursement methodologies, |
| 33 | including competitive bidding pursuant to s. 287.057, designed |
| 34 | to facilitate the cost-effective purchase of a case-managed |
| 35 | continuum of care. The agency shall also require providers to |
| 36 | minimize the exposure of recipients to the need for acute |
| 37 | inpatient, custodial, and other institutional care and the |
| 38 | inappropriate or unnecessary use of high-cost services. The |
| 39 | agency shall contract with a vendor to monitor and evaluate the |
| 40 | clinical practice patterns of providers in order to identify |
| 41 | trends that are outside the normal practice patterns of a |
| 42 | provider's professional peers or the national guidelines of a |
| 43 | provider's professional association. The vendor must be able to |
| 44 | provide information and counseling to a provider whose practice |
| 45 | patterns are outside the norms, in consultation with the agency, |
| 46 | to improve patient care and reduce inappropriate utilization. |
| 47 | The agency may mandate prior authorization, drug therapy |
| 48 | management, or disease management participation for certain |
| 49 | populations of Medicaid beneficiaries, certain drug classes, or |
| 50 | particular drugs to prevent fraud, abuse, overuse, and possible |
| 51 | dangerous drug interactions. The Pharmaceutical and Therapeutics |
| 52 | Committee shall make recommendations to the agency on drugs for |
| 53 | which prior authorization is required. The agency shall inform |
| 54 | the Pharmaceutical and Therapeutics Committee of its decisions |
| 55 | regarding drugs subject to prior authorization. The agency is |
| 56 | authorized to limit the entities it contracts with or enrolls as |
| 57 | Medicaid providers by developing a provider network through |
| 58 | provider credentialing. The agency may competitively bid single- |
| 59 | source-provider contracts if procurement of goods or services |
| 60 | results in demonstrated cost savings to the state without |
| 61 | limiting access to care. The agency may limit its network based |
| 62 | on the assessment of beneficiary access to care, provider |
| 63 | availability, provider quality standards, time and distance |
| 64 | standards for access to care, the cultural competence of the |
| 65 | provider network, demographic characteristics of Medicaid |
| 66 | beneficiaries, practice and provider-to-beneficiary standards, |
| 67 | appointment wait times, beneficiary use of services, provider |
| 68 | turnover, provider profiling, provider licensure history, |
| 69 | previous program integrity investigations and findings, peer |
| 70 | review, provider Medicaid policy and billing compliance records, |
| 71 | clinical and medical record audits, and other factors. Providers |
| 72 | shall not be entitled to enrollment in the Medicaid provider |
| 73 | network. The agency shall determine instances in which allowing |
| 74 | Medicaid beneficiaries to purchase durable medical equipment and |
| 75 | other goods is less expensive to the Medicaid program than long- |
| 76 | term rental of the equipment or goods. The agency may establish |
| 77 | rules to facilitate purchases in lieu of long-term rentals in |
| 78 | order to protect against fraud and abuse in the Medicaid program |
| 79 | as defined in s. 409.913. The agency may seek federal waivers |
| 80 | necessary to administer these policies. |
| 81 | (51) The agency shall work with the Agency for Persons |
| 82 | with Disabilities to develop a model home and community-based |
| 83 | waiver to serve children and adults who are diagnosed with |
| 84 | familial dysautonomia or Riley-Day syndrome caused by a mutation |
| 85 | of the IKBKAP gene on chromosome 9. The agency shall seek |
| 86 | federal waiver approval and implement the approved waiver |
| 87 | subject to the availability of funds and any limitations |
| 88 | provided in the General Appropriations Act. The agency may adopt |
| 89 | rules to implement this waiver program. |
| 90 | Section 2. This act shall take effect upon becoming a law. |