Florida Senate - 2011                        COMMITTEE AMENDMENT
       Bill No. SB 1922
       
       
       
       
       
       
                                Barcode 568294                          
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                  Comm: RCS            .                                
                  04/25/2011           .                                
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       The Committee on Banking and Insurance (Oelrich) recommended the
       following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Delete everything after the enacting clause
    4  and insert:
    5         Section 1. Section 408.910, Florida Statutes, is amended to
    6  read:
    7         408.910 Florida Health Choices Program.—
    8         (1) LEGISLATIVE INTENT.—The Legislature finds that a
    9  significant number of the residents of this state do not have
   10  adequate access to affordable, quality health care. The
   11  Legislature further finds that increasing access to affordable,
   12  quality health care can be best accomplished by establishing a
   13  competitive market for purchasing health insurance and health
   14  services. It is therefore the intent of the Legislature to
   15  create the Florida Health Choices Program to:
   16         (a) Expand opportunities for Floridians to purchase
   17  affordable health insurance and health services.
   18         (b) Preserve the benefits of employment-sponsored insurance
   19  while easing the administrative burden for employers who offer
   20  these benefits.
   21         (c) Enable individual choice in both the manner and amount
   22  of health care purchased.
   23         (d) Provide for the purchase of individual, portable health
   24  care coverage.
   25         (e) Disseminate information to consumers on the price and
   26  quality of health services.
   27         (f) Sponsor a competitive market that stimulates product
   28  innovation, quality improvement, and efficiency in the
   29  production and delivery of health services.
   30         (2) DEFINITIONS.—As used in this section, the term:
   31         (a) “Corporation” means the Florida Health Choices, Inc.,
   32  established under this section.
   33         (b) “Corporation’s marketplace” means the single,
   34  centralized market established by the program which facilitates
   35  the purchase of products made available in the marketplace.
   36         (c)(b) “Health insurance agent” means an agent licensed
   37  under part IV of chapter 626.
   38         (d)(c) “Insurer” means an entity licensed under chapter 624
   39  which offers an individual health insurance policy or a group
   40  health insurance policy, a preferred provider organization as
   41  defined in s. 627.6471, or an exclusive provider organization as
   42  defined in s. 627.6472, a health maintenance organization
   43  licensed under part I of chapter 641, or a prepaid limited
   44  health service organization or discount medical plan
   45  organization licensed under chapter 636.
   46         (e)(d) “Program” means the Florida Health Choices Program
   47  established by this section.
   48         (3) PROGRAM PURPOSE AND COMPONENTS.—The Florida Health
   49  Choices Program is created as a single, centralized market for
   50  the sale and purchase of various products that enable
   51  individuals to pay for health care. These products include, but
   52  are not limited to, health insurance plans, health maintenance
   53  organization plans, prepaid services, service contracts, and
   54  flexible spending accounts. The components of the program
   55  include:
   56         (a) Enrollment of employers.
   57         (b) Administrative services for participating employers,
   58  including:
   59         1. Assistance in seeking federal approval of cafeteria
   60  plans.
   61         2. Collection of premiums and other payments.
   62         3. Management of individual benefit accounts.
   63         4. Distribution of premiums to insurers and payments to
   64  other eligible vendors.
   65         5. Assistance for participants in complying with reporting
   66  requirements.
   67         (c) Services to individual participants, including:
   68         1. Information about available products and participating
   69  vendors.
   70         2. Assistance with assessing the benefits and limits of
   71  each product, including information necessary to distinguish
   72  between policies offering creditable coverage and other products
   73  available through the program.
   74         3. Account information to assist individual participants
   75  with managing available resources.
   76         4. Services that promote healthy behaviors.
   77         (d) Recruitment of vendors, including insurers, health
   78  maintenance organizations, prepaid clinic service providers,
   79  provider service networks, and other providers.
   80         (e) Certification of vendors to ensure capability,
   81  reliability, and validity of offerings.
   82         (f) Collection of data, monitoring, assessment, and
   83  reporting of vendor performance.
   84         (g) Information services for individuals and employers.
   85         (h) Program evaluation.
   86         (4) ELIGIBILITY AND PARTICIPATION.—Participation in the
   87  program is voluntary and is shall be available to employers,
   88  individuals, vendors, and health insurance agents as specified
   89  in this subsection.
   90         (a) Employers eligible to enroll in the program include:
   91         1. Employers that meet criteria established by the
   92  corporation and elect to make their employees eligible for one
   93  or more health products offered through the program have 1 to 50
   94  employees.
   95         2. Fiscally constrained counties described in s. 218.67.
   96         3. Municipalities having populations of fewer than 50,000
   97  residents.
   98         4. School districts in fiscally constrained counties.
   99         5. Statutory rural hospitals.
  100         (b) Individuals eligible to participate in the program
  101  include:
  102         1. Individual employees of enrolled employers.
  103         2. State employees not eligible for state employee health
  104  benefits.
  105         3. State retirees.
  106         4. Medicaid reform participants who opt out select the opt
  107  out provision of reform.
  108         5. Statutory rural hospitals.
  109         (c) Employers who choose to participate in the program may
  110  enroll by complying with the procedures established by the
  111  corporation. The procedures must include, but are not limited
  112  to:
  113         1. Submission of required information.
  114         2. Compliance with federal tax requirements for the
  115  establishment of a cafeteria plan, pursuant to s. 125 of the
  116  Internal Revenue Code, including designation of the employer’s
  117  plan as a premium payment plan, a salary reduction plan that has
  118  flexible spending arrangements, or a salary reduction plan that
  119  has a premium payment and flexible spending arrangements.
  120         3. Determination of the employer’s contribution, if any,
  121  per employee, provided that such contribution is equal for each
  122  eligible employee.
  123         4. Establishment of payroll deduction procedures, subject
  124  to the agreement of each individual employee who voluntarily
  125  participates in the program.
  126         5. Designation of the corporation as the third-party
  127  administrator for the employer’s health benefit plan.
  128         6. Identification of eligible employees.
  129         7. Arrangement for periodic payments.
  130         8. Employer notification to employees of the intent to
  131  transfer from an existing employee health plan to the program at
  132  least 90 days before the transition.
  133         (d) All eligible vendors who choose to participate and the
  134  products and services that the vendors are permitted to sell are
  135  as follows:
  136         1. Insurers licensed under chapter 624 may sell health
  137  insurance policies, limited benefit policies, other risk-bearing
  138  coverage, and other products or services.
  139         2. Health maintenance organizations licensed under part I
  140  of chapter 641 may sell health maintenance contracts insurance
  141  policies, limited benefit policies, other risk-bearing products,
  142  and other products or services.
  143         3. Prepaid limited health service organizations may sell
  144  products and services as authorized under part I of chapter 636,
  145  and discount medical plan organizations may sell products and
  146  services as authorized under part II of chapter 636.
  147         4.3. Prepaid health clinic service providers licensed under
  148  part II of chapter 641 may sell prepaid service contracts and
  149  other arrangements for a specified amount and type of health
  150  services or treatments.
  151         5.4. Health care providers, including hospitals and other
  152  licensed health facilities, health care clinics, licensed health
  153  professionals, pharmacies, and other licensed health care
  154  providers, may sell service contracts and arrangements for a
  155  specified amount and type of health services or treatments.
  156         6.5. Provider organizations, including service networks,
  157  group practices, professional associations, and other
  158  incorporated organizations of providers, may sell service
  159  contracts and arrangements for a specified amount and type of
  160  health services or treatments.
  161         7.6. Corporate entities providing specific health services
  162  in accordance with applicable state law may sell service
  163  contracts and arrangements for a specified amount and type of
  164  health services or treatments.
  165  
  166         A vendor described in subparagraphs 4.-7. 3.-6. may not
  167  sell products that provide risk-bearing coverage unless that
  168  vendor is authorized under a certificate of authority issued by
  169  the Office of Insurance Regulation and is authorized to provide
  170  coverage in the relevant geographic area under the provisions of
  171  the Florida Insurance Code. Otherwise eligible vendors may be
  172  excluded from participating in the program for deceptive or
  173  predatory practices, financial insolvency, or failure to comply
  174  with the terms of the participation agreement or other standards
  175  set by the corporation.
  176         (e) Any risk-bearing product available under subparagraphs
  177  (d)1.-4. must be approved by the Office of Insurance Regulation.
  178  Any non-risk-bearing product must be approved by the
  179  corporation.
  180         (f)(e) Eligible individuals may voluntarily continue
  181  participation in the program regardless of subsequent changes in
  182  job status or Medicaid eligibility. Individuals who join the
  183  program may participate by complying with the procedures
  184  established by the corporation. These procedures must include,
  185  but are not limited to:
  186         1. Submission of required information.
  187         2. Authorization for payroll deduction.
  188         3. Compliance with federal tax requirements.
  189         4. Arrangements for payment in the event of job changes.
  190         5. Selection of products and services.
  191         (g)(f) Vendors who choose to participate in the program may
  192  enroll by complying with the procedures established by the
  193  corporation. These procedures may must include, but are not
  194  limited to:
  195         1. Submission of required information, including a complete
  196  description of the coverage, services, provider network, payment
  197  restrictions, and other requirements of each product offered
  198  through the program.
  199         2. Execution of an agreement that to make all risk-bearing
  200  products offered through the program are in compliance with the
  201  insurance code and are guaranteed-issue policies, subject to
  202  preexisting condition exclusions established by the corporation.
  203         3. Execution of an agreement that prohibits refusal to sell
  204  any offered non-risk-bearing product to a participant who elects
  205  to buy it.
  206         4. Establishment of product prices based on age, gender,
  207  family composition, and location of the individual participant,
  208  which may include medical underwriting.
  209         5. Arrangements for receiving payment for enrolled
  210  participants.
  211         6. Participation in ongoing reporting processes established
  212  by the corporation.
  213         7. Compliance with grievance procedures established by the
  214  corporation.
  215         (h)(g) Health insurance agents licensed under part IV of
  216  chapter 626 are eligible to voluntarily participate as buyers’
  217  representatives. A buyer’s representative acts on behalf of an
  218  individual purchasing health insurance and health services
  219  through the program by providing information about products and
  220  services available through the program and assisting the
  221  individual with both the decision and the procedure of selecting
  222  specific products. Serving as a buyer’s representative does not
  223  constitute a conflict of interest with continuing
  224  responsibilities as a health insurance agent if the relationship
  225  between each agent and any participating vendor is disclosed
  226  before advising an individual participant about the products and
  227  services available through the program. In order to participate,
  228  a health insurance agent shall comply with the procedures
  229  established by the corporation, including:
  230         1. Completion of training requirements.
  231         2. Execution of a participation agreement specifying the
  232  terms and conditions of participation.
  233         3. Disclosure of any appointments to solicit insurance or
  234  procure applications for vendors participating in the program.
  235         4. Arrangements to receive payment from the corporation for
  236  services as a buyer’s representative.
  237         (5) PRODUCTS.—
  238         (a) The products that may be made available for purchase
  239  through the program include, but are not limited to:
  240         1. Health insurance policies.
  241         2. Limited benefit plans.
  242         3. Prepaid clinic services.
  243         4. Service contracts.
  244         5. Arrangements for purchase of specific amounts and types
  245  of health services and treatments.
  246         6. Flexible spending accounts.
  247         7. Health maintenance contracts.
  248         (b) Health insurance policies, health maintenance
  249  contracts, limited benefit plans, prepaid service contracts, and
  250  other contracts for services must ensure the availability of
  251  covered services and benefits to participating individuals for
  252  at least 1 full enrollment year.
  253         (c) Products may be offered for multiyear periods provided
  254  the price of the product is specified for the entire period or
  255  for each separately priced segment of the policy or contract.
  256         (d) The corporation shall provide a disclosure form for
  257  consumers to acknowledge their understanding of the nature of,
  258  and any limitations to, the benefits provided by the products
  259  and services being purchased by the consumer.
  260         (e) The corporation must determine that making the plan
  261  available through the program is in the interest of eligible
  262  individuals and eligible employers in the state.
  263         (6) PRICING.—Prices for the products sold through the
  264  program must be transparent to participants and established by
  265  the vendors. Risk-bearing products approved by the Office of
  266  Insurance Regulation must be priced pursuant to state law
  267  governing the rates of insurance product based on age, gender,
  268  and location of participants. The corporation shall develop a
  269  methodology for evaluating the actuarial soundness of products
  270  offered through the program. The methodology shall be reviewed
  271  by the Office of Insurance Regulation prior to use by the
  272  corporation. Before making the product available to individual
  273  participants, the corporation shall use the methodology to
  274  compare the expected health care costs for the covered services
  275  and benefits to the vendor’s price for that coverage. The
  276  results shall be reported to individuals participating in the
  277  program. Once established, the price set by the vendor must
  278  remain in force for at least 1 year and may only be redetermined
  279  by the vendor at the next annual enrollment period. The
  280  corporation shall annually assess a surcharge for each premium
  281  or price set by a participating vendor. The surcharge may not be
  282  more than 2.5 percent of the price and shall be used to generate
  283  funding for administrative services provided by the corporation
  284  and payments to buyers’ representatives.
  285         (7) MARKETPLACE EXCHANGE PROCESS.—The program shall provide
  286  a single, centralized market for purchase of health insurance,
  287  health maintenance contracts, and other health products and
  288  services. Purchases may be made by participating individuals
  289  over the Internet or through the services of a participating
  290  health insurance agent. Information about each product and
  291  service available through the program shall be made available
  292  through printed material and an interactive Internet website. A
  293  participant needing personal assistance to select products and
  294  services shall be referred to a participating agent in his or
  295  her area.
  296         (a) Participation in the program may begin at any time
  297  during a year after the employer completes enrollment and meets
  298  the requirements specified by the corporation pursuant to
  299  paragraph (4)(c).
  300         (b) Initial selection of products and services must be made
  301  by an individual participant within 60 days after the date the
  302  individual’s employer qualified for participation. An individual
  303  who fails to enroll in products and services by the end of this
  304  period is limited to participation in flexible spending account
  305  services until the next annual enrollment period.
  306         (c) Initial enrollment periods for each product selected by
  307  an individual participant must last at least 12 months, unless
  308  the individual participant specifically agrees to a different
  309  enrollment period.
  310         (d) If an individual has selected one or more products and
  311  enrolled in those products for at least 12 months or any other
  312  period specifically agreed to by the individual participant,
  313  changes in selected products and services may only be made
  314  during the annual enrollment period established by the
  315  corporation.
  316         (e) The limits established in paragraphs (b)-(d) apply to
  317  any risk-bearing product that promises future payment or
  318  coverage for a variable amount of benefits or services. The
  319  limits do not apply to initiation of flexible spending plans if
  320  those plans are not associated with specific high-deductible
  321  insurance policies or the use of spending accounts for any
  322  products offering individual participants specific amounts and
  323  types of health services and treatments at a contracted price.
  324         (8) CONSUMER INFORMATION.—The corporation shall:
  325         (a) Establish a secure website to facilitate the purchase
  326  of products and services by participating individuals. The
  327  website must provide information about each product or service
  328  available through the program.
  329         (b) Inform individuals about other public health care
  330  programs.
  331         (a) Prior to making a risk-bearing product available
  332  through the program, the corporation shall provide information
  333  regarding the product to the Office of Insurance Regulation. The
  334  office shall review the product information and provide consumer
  335  information and a recommendation on the risk-bearing product to
  336  the corporation within 30 days after receiving the product
  337  information.
  338         1. Upon receiving a recommendation that a risk-bearing
  339  product should be made available in the marketplace, the
  340  corporation may include the product on its website. If the
  341  consumer information and recommendation is not received within
  342  30 days, the corporation may make the risk-bearing product
  343  available on the website without consumer information from the
  344  office.
  345         2. Upon receiving a recommendation that a risk-bearing
  346  product should not be made available in the marketplace, the
  347  risk-bearing product may be included as an eligible product in
  348  the marketplace and on its website only if a majority of the
  349  board of directors vote to include the product.
  350         (b) If a risk-bearing product is made available on the
  351  website, the corporation shall make the consumer information and
  352  office recommendation available on the website and in print
  353  format. The corporation shall make late-submitted and ongoing
  354  updates to consumer information available on the website and in
  355  print format.
  356         (9) RISK POOLING.—The program may use shall utilize methods
  357  for pooling the risk of individual participants and preventing
  358  selection bias. These methods may shall include, but are not
  359  limited to, a postenrollment risk adjustment of the premium
  360  payments to the vendors. The corporation may shall establish a
  361  methodology for assessing the risk of enrolled individual
  362  participants based on data reported annually by the vendors
  363  about their enrollees. Distribution Monthly distributions of
  364  payments to the vendors may shall be adjusted based on the
  365  assessed relative risk profile of the enrollees in each risk
  366  bearing product for the most recent period for which data is
  367  available.
  368         (10) EXEMPTIONS.—
  369         (a) Products, other than the risk-bearing products set
  370  forth in subparagraph (4)(d)1.-4., Policies sold as part of the
  371  program are not subject to the licensing requirements of the
  372  Florida Insurance Code, as defined in s. 624.01 chapter 641, or
  373  the mandated offerings or coverages established in part VI of
  374  chapter 627 and chapter 641.
  375         (b) The corporation may act as an administrator as defined
  376  in s. 626.88 but is not required to be certified pursuant to
  377  part VII of chapter 626. However, a third party administrator
  378  used by the corporation must be certified under part VII of
  379  chapter 626.
  380         (11) CORPORATION.—There is created the Florida Health
  381  Choices, Inc., which shall be registered, incorporated,
  382  organized, and operated in compliance with part III of chapter
  383  112 and chapters 119, 286, and 617. The purpose of the
  384  corporation is to administer the program created in this section
  385  and to conduct such other business as may further the
  386  administration of the program.
  387         (a) The corporation shall be governed by a 15-member board
  388  of directors consisting of:
  389         1. Three ex officio, nonvoting members to include:
  390         a. The Secretary of Health Care Administration or a
  391  designee with expertise in health care services.
  392         b. The Secretary of Management Services or a designee with
  393  expertise in state employee benefits.
  394         c. The commissioner of the Office of Insurance Regulation
  395  or a designee with expertise in insurance regulation.
  396         2. Four members appointed by and serving at the pleasure of
  397  the Governor.
  398         3. Four members appointed by and serving at the pleasure of
  399  the President of the Senate.
  400         4. Four members appointed by and serving at the pleasure of
  401  the Speaker of the House of Representatives.
  402         5. Board members may not include insurers, health insurance
  403  agents or brokers, health care providers, health maintenance
  404  organizations, prepaid service providers, or any other entity,
  405  affiliate or subsidiary of eligible vendors.
  406         (b) Members shall be appointed for terms of up to 3 years.
  407  Any member is eligible for reappointment. A vacancy on the board
  408  shall be filled for the unexpired portion of the term in the
  409  same manner as the original appointment.
  410         (c) The board shall select a chief executive officer for
  411  the corporation who shall be responsible for the selection of
  412  such other staff as may be authorized by the corporation’s
  413  operating budget as adopted by the board.
  414         (d) Board members are entitled to receive, from funds of
  415  the corporation, reimbursement for per diem and travel expenses
  416  as provided by s. 112.061. No other compensation is authorized.
  417         (e) There is no liability on the part of, and no cause of
  418  action shall arise against, any member of the board or its
  419  employees or agents for any action taken by them in the
  420  performance of their powers and duties under this section.
  421         (f) The board shall develop and adopt bylaws and other
  422  corporate procedures as necessary for the operation of the
  423  corporation and carrying out the purposes of this section. The
  424  bylaws shall:
  425         1. Specify procedures for selection of officers and
  426  qualifications for reappointment, provided that no board member
  427  shall serve more than 9 consecutive years.
  428         2. Require an annual membership meeting that provides an
  429  opportunity for input and interaction with individual
  430  participants in the program.
  431         3. Specify policies and procedures regarding conflicts of
  432  interest, including the provisions of part III of chapter 112,
  433  which prohibit a member from participating in any decision that
  434  would inure to the benefit of the member or the organization
  435  that employs the member. The policies and procedures shall also
  436  require public disclosure of the interest that prevents the
  437  member from participating in a decision on a particular matter.
  438         (g) The corporation may exercise all powers granted to it
  439  under chapter 617 necessary to carry out the purposes of this
  440  section, including, but not limited to, the power to receive and
  441  accept grants, loans, or advances of funds from any public or
  442  private agency and to receive and accept from any source
  443  contributions of money, property, labor, or any other thing of
  444  value to be held, used, and applied for the purposes of this
  445  section.
  446         (h) The corporation may establish technical advisory panels
  447  consisting of interested parties, including consumers, health
  448  care providers, individuals with expertise in insurance
  449  regulation, and insurers.
  450         (i) The corporation shall:
  451         1. Determine eligibility of employers, vendors,
  452  individuals, and agents in accordance with subsection (4).
  453         2. Establish procedures necessary for the operation of the
  454  program, including, but not limited to, procedures for
  455  application, enrollment, risk assessment, risk adjustment, plan
  456  administration, performance monitoring, and consumer education.
  457         3. Arrange for collection of contributions from
  458  participating employers and individuals.
  459         4. Arrange for payment of premiums and other appropriate
  460  disbursements based on the selections of products and services
  461  by the individual participants.
  462         5. Establish criteria for disenrollment of participating
  463  individuals based on failure to pay the individual’s share of
  464  any contribution required to maintain enrollment in selected
  465  products.
  466         6. Establish criteria for exclusion of vendors pursuant to
  467  paragraph (4)(d).
  468         7. Develop and implement a plan for promoting public
  469  awareness of and participation in the program.
  470         8. Secure staff and consultant services necessary to the
  471  operation of the program.
  472         9. Establish policies and procedures regarding
  473  participation in the program for individuals, vendors, health
  474  insurance agents, and employers.
  475         10. Provide for the operation of a toll-free hotline to
  476  respond to requests for assistance.
  477         11. Provide for initial, open, and special enrollment
  478  periods not to exceed 60 days.
  479         12. Establish options for employer participation which may
  480  conform with common insurance practices.
  481         10. Develop a plan, in coordination with the Department of
  482  Revenue, to establish tax credits or refunds for employers that
  483  participate in the program. The corporation shall submit the
  484  plan to the Governor, the President of the Senate, and the
  485  Speaker of the House of Representatives by January 1, 2009.
  486         (12) REPORT.—Beginning in the 2009-2010 fiscal year, submit
  487  by February 1 an annual report to the Governor, the President of
  488  the Senate, and the Speaker of the House of Representatives
  489  documenting the corporation’s activities in compliance with the
  490  duties delineated in this section.
  491         (13) PROGRAM INTEGRITY.—To ensure program integrity and to
  492  safeguard the financial transactions made under the auspices of
  493  the program, the corporation is authorized to establish
  494  qualifying criteria and certification procedures for vendors,
  495  require performance bonds or other guarantees of ability to
  496  complete contractual obligations, monitor the performance of
  497  vendors, and enforce the agreements of the program through
  498  financial penalty or disqualification from the program.
  499         Section 2. Section 409.821, Florida Statutes, is amended to
  500  read:
  501         409.821 Florida Kidcare program public records exemption.—
  502         (1) Personal identifying information of a Florida Kidcare
  503  program applicant or enrollee, as defined in s. 409.811, held by
  504  the Agency for Health Care Administration, the Department of
  505  Children and Family Services, the Department of Health, or the
  506  Florida Healthy Kids Corporation is confidential and exempt from
  507  s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
  508         (2)(a) Upon request, such information shall be disclosed
  509  to:
  510         1. Another governmental entity in the performance of its
  511  official duties and responsibilities;
  512         2. The Department of Revenue for purposes of administering
  513  the state Title IV-D program; or
  514         3. The Florida Health Choices, Inc., for the purpose of
  515  administering the program authorized pursuant to s. 408.910; or
  516         4.3. Any person who has the written consent of the program
  517  applicant.
  518         (b) This section does not prohibit an enrollee’s legal
  519  guardian from obtaining confirmation of coverage, dates of
  520  coverage, the name of the enrollee’s health plan, and the amount
  521  of premium being paid.
  522         (3) This exemption applies to any information identifying a
  523  Florida Kidcare program applicant or enrollee held by the Agency
  524  for Health Care Administration, the Department of Children and
  525  Family Services, the Department of Health, or the Florida
  526  Healthy Kids Corporation before, on, or after the effective date
  527  of this exemption.
  528         (4) A knowing and willful violation of this section is a
  529  misdemeanor of the second degree, punishable as provided in s.
  530  775.082 or s. 775.083.
  531         Section 3. Subsection (41) of section 409.912, Florida
  532  Statutes, is amended to read:
  533         409.912 Cost-effective purchasing of health care.—The
  534  agency shall purchase goods and services for Medicaid recipients
  535  in the most cost-effective manner consistent with the delivery
  536  of quality medical care. To ensure that medical services are
  537  effectively utilized, the agency may, in any case, require a
  538  confirmation or second physician’s opinion of the correct
  539  diagnosis for purposes of authorizing future services under the
  540  Medicaid program. This section does not restrict access to
  541  emergency services or poststabilization care services as defined
  542  in 42 C.F.R. part 438.114. Such confirmation or second opinion
  543  shall be rendered in a manner approved by the agency. The agency
  544  shall maximize the use of prepaid per capita and prepaid
  545  aggregate fixed-sum basis services when appropriate and other
  546  alternative service delivery and reimbursement methodologies,
  547  including competitive bidding pursuant to s. 287.057, designed
  548  to facilitate the cost-effective purchase of a case-managed
  549  continuum of care. The agency shall also require providers to
  550  minimize the exposure of recipients to the need for acute
  551  inpatient, custodial, and other institutional care and the
  552  inappropriate or unnecessary use of high-cost services. The
  553  agency shall contract with a vendor to monitor and evaluate the
  554  clinical practice patterns of providers in order to identify
  555  trends that are outside the normal practice patterns of a
  556  provider’s professional peers or the national guidelines of a
  557  provider’s professional association. The vendor must be able to
  558  provide information and counseling to a provider whose practice
  559  patterns are outside the norms, in consultation with the agency,
  560  to improve patient care and reduce inappropriate utilization.
  561  The agency may mandate prior authorization, drug therapy
  562  management, or disease management participation for certain
  563  populations of Medicaid beneficiaries, certain drug classes, or
  564  particular drugs to prevent fraud, abuse, overuse, and possible
  565  dangerous drug interactions. The Pharmaceutical and Therapeutics
  566  Committee shall make recommendations to the agency on drugs for
  567  which prior authorization is required. The agency shall inform
  568  the Pharmaceutical and Therapeutics Committee of its decisions
  569  regarding drugs subject to prior authorization. The agency is
  570  authorized to limit the entities it contracts with or enrolls as
  571  Medicaid providers by developing a provider network through
  572  provider credentialing. The agency may competitively bid single
  573  source-provider contracts if procurement of goods or services
  574  results in demonstrated cost savings to the state without
  575  limiting access to care. The agency may limit its network based
  576  on the assessment of beneficiary access to care, provider
  577  availability, provider quality standards, time and distance
  578  standards for access to care, the cultural competence of the
  579  provider network, demographic characteristics of Medicaid
  580  beneficiaries, practice and provider-to-beneficiary standards,
  581  appointment wait times, beneficiary use of services, provider
  582  turnover, provider profiling, provider licensure history,
  583  previous program integrity investigations and findings, peer
  584  review, provider Medicaid policy and billing compliance records,
  585  clinical and medical record audits, and other factors. Providers
  586  shall not be entitled to enrollment in the Medicaid provider
  587  network. The agency shall determine instances in which allowing
  588  Medicaid beneficiaries to purchase durable medical equipment and
  589  other goods is less expensive to the Medicaid program than long
  590  term rental of the equipment or goods. The agency may establish
  591  rules to facilitate purchases in lieu of long-term rentals in
  592  order to protect against fraud and abuse in the Medicaid program
  593  as defined in s. 409.913. The agency may seek federal waivers
  594  necessary to administer these policies.
  595         (41) The agency shall establish provide for the development
  596  of a demonstration project by establishment in Miami-Dade County
  597  of a long-term-care facility and a psychiatric facility licensed
  598  pursuant to chapter 395 to improve access to health care for a
  599  predominantly minority, medically underserved, and medically
  600  complex population and to evaluate alternatives to nursing home
  601  care and general acute care for such population. Such project is
  602  to be located in a health care condominium and collocated
  603  colocated with licensed facilities providing a continuum of
  604  care. These projects are The establishment of this project is
  605  not subject to the provisions of s. 408.036 or s. 408.039.
  606         Section 4. This act shall take effect July 1, 2011.
  607  
  608  ================= T I T L E  A M E N D M E N T ================
  609  And the title is amended as follows:
  610  
  611         Delete everything before the enacting clause
  612  and insert:
  613                        A bill to be entitled                      
  614         An act relating to health and human services; amending
  615         s. 408.910, F.S.; providing and revising definitions;
  616         revising eligibility requirements for participation in
  617         the Florida Health Choices Program; providing that
  618         statutory rural hospitals are eligible as employers
  619         rather than participants under the program; permitting
  620         specified eligible vendors to sell health maintenance
  621         contracts or products and services; requiring certain
  622         risk-bearing products offered by insurers to be
  623         approved by the Office of Insurance Regulation;
  624         providing requirements for product certification;
  625         providing duties of the Florida Health Choices, Inc.,
  626         including maintenance of a toll-free telephone hotline
  627         to respond to requests for assistance; providing for
  628         enrollment periods; providing for certain risk pooling
  629         data used by the corporation to be reported annually;
  630         amending s. 409.821, F.S.; authorizing personal
  631         identifying information of a Florida Kidcare program
  632         applicant to be disclosed to the Florida Health
  633         Choices, Inc., to administer the program; amending s.
  634         409.912, F.S.; requiring the Agency for Health Care
  635         Administration to establish a demonstration project in
  636         Miami-Dade County of a long-term-care facility and a
  637         psychiatric facility to improve access to health care
  638         by medically underserved persons; providing an
  639         effective date.