HB 7067

A bill to be entitled
2An act relating to a model fixed-payment service delivery
3system for people with developmental disabilities;
4amending s. 409.912, F.S.; requiring the Agency for Health
5Care Administration to implement federal waivers to
6administer a model fixed-payment service delivery system
7for Medicaid recipients with developmental disabilities;
8providing legislative intent; providing for implementation
9of the system on a pilot basis in certain areas of the
10state; providing for administration of the system by the
11Agency for Persons with Disabilities; providing
12requirements for selection of entities to operate the
13system; providing for mandatory enrollment in system pilot
14areas; requiring an evaluation of the system; requiring
15the agency to submit a report to the Governor and
16Legislature; authorizing the agency to seek certain
17waivers and adopt rules; requiring the agency to receive
18specific authorization prior to expanding the system;
19providing an effective date.
21Be It Enacted by the Legislature of the State of Florida:
23     Section 1.  Subsection (53) is added to section 409.912,
24Florida Statutes, to read:
25     409.912  Cost-effective purchasing of health care.--The
26agency shall purchase goods and services for Medicaid recipients
27in the most cost-effective manner consistent with the delivery
28of quality medical care. To ensure that medical services are
29effectively utilized, the agency may, in any case, require a
30confirmation or second physician's opinion of the correct
31diagnosis for purposes of authorizing future services under the
32Medicaid program. This section does not restrict access to
33emergency services or poststabilization care services as defined
34in 42 C.F.R. part 438.114. Such confirmation or second opinion
35shall be rendered in a manner approved by the agency. The agency
36shall maximize the use of prepaid per capita and prepaid
37aggregate fixed-sum basis services when appropriate and other
38alternative service delivery and reimbursement methodologies,
39including competitive bidding pursuant to s. 287.057, designed
40to facilitate the cost-effective purchase of a case-managed
41continuum of care. The agency shall also require providers to
42minimize the exposure of recipients to the need for acute
43inpatient, custodial, and other institutional care and the
44inappropriate or unnecessary use of high-cost services. The
45agency shall contract with a vendor to monitor and evaluate the
46clinical practice patterns of providers in order to identify
47trends that are outside the normal practice patterns of a
48provider's professional peers or the national guidelines of a
49provider's professional association. The vendor must be able to
50provide information and counseling to a provider whose practice
51patterns are outside the norms, in consultation with the agency,
52to improve patient care and reduce inappropriate utilization.
53The agency may mandate prior authorization, drug therapy
54management, or disease management participation for certain
55populations of Medicaid beneficiaries, certain drug classes, or
56particular drugs to prevent fraud, abuse, overuse, and possible
57dangerous drug interactions. The Pharmaceutical and Therapeutics
58Committee shall make recommendations to the agency on drugs for
59which prior authorization is required. The agency shall inform
60the Pharmaceutical and Therapeutics Committee of its decisions
61regarding drugs subject to prior authorization. The agency is
62authorized to limit the entities it contracts with or enrolls as
63Medicaid providers by developing a provider network through
64provider credentialing. The agency may competitively bid single-
65source-provider contracts if procurement of goods or services
66results in demonstrated cost savings to the state without
67limiting access to care. The agency may limit its network based
68on the assessment of beneficiary access to care, provider
69availability, provider quality standards, time and distance
70standards for access to care, the cultural competence of the
71provider network, demographic characteristics of Medicaid
72beneficiaries, practice and provider-to-beneficiary standards,
73appointment wait times, beneficiary use of services, provider
74turnover, provider profiling, provider licensure history,
75previous program integrity investigations and findings, peer
76review, provider Medicaid policy and billing compliance records,
77clinical and medical record audits, and other factors. Providers
78shall not be entitled to enrollment in the Medicaid provider
79network. The agency shall determine instances in which allowing
80Medicaid beneficiaries to purchase durable medical equipment and
81other goods is less expensive to the Medicaid program than long-
82term rental of the equipment or goods. The agency may establish
83rules to facilitate purchases in lieu of long-term rentals in
84order to protect against fraud and abuse in the Medicaid program
85as defined in s. 409.913. The agency may seek federal waivers
86necessary to administer these policies.
87     (53)  By December 1, 2007, the Agency for Health Care
88Administration, in consultation with the Agency for Persons with
89Disabilities, shall create a model fixed-payment service
90delivery system for persons with developmental disabilities who
91receive services under the developmental disabilities waiver
92program administered by the Agency for Persons with
93Disabilities. Persons with developmental disabilities who
94receive services under the family and supported living waiver
95program or the consumer-directed care plus waiver program
96administered by the Agency for Persons with Disabilities may
97also be included in the system if the agency determines that
98such inclusion is feasible and will improve coordination of care
99and management of costs. The system must transfer and combine
100all services funded by Medicaid waiver programs and services
101funded only by the state, including room and board and supported
102living payments, for individuals who participate in the system.
103     (a)  The Legislature intends that the system provide
104recipients in Medicaid waiver programs with a coordinated system
105of services, increased cost predictability, and a stabilized
106rate of increase in Medicaid expenditures compared to Medicaid
107expenditures in the pilot areas specified in paragraph (b) for
108the 3 years before the system was implemented while ensuring:
109     1.  Consumer choice.
110     2.  Opportunities for consumer-directed services.
111     3.  Access to medically necessary services.
112     4.  Coordination of community-based services.
113     5.  Reductions in the unnecessary use of services.
114     (b)  The agency shall implement the system on a pilot basis
115in Area 1 of the Agency for Persons with Disabilities and in
116another area that is determined by the agency, in consultation
117with the Agency for Persons with Disabilities, to be an
118appropriate pilot site. After completion of the development
119phase of the system, attainment of necessary federal approval,
120procurement of qualified entities, and rate setting, the agency
121shall delegate administration of the system to the Agency for
122Persons with Disabilities. The Agency for Persons with
123Disabilities shall administer contracts with qualified entities
124and provide quality assurance, monitoring oversight, and other
125duties necessary for the system. The enrollment of Medicaid
126waiver recipients in the system in pilot areas shall be
128     (c)  The agency shall use a competitive procurement process
129to select entities to operate the system. Entities eligible to
130submit bids include community service networks that meet
131standards of financial solvency, as defined and determined by
132the agency in consultation with the Agency for Persons with
133Disabilities and the Office of Insurance Regulation, and that
134are able to take on financial risk for managed care. The agency
135shall ensure that bid requirements for entities include, but are
136not limited to, standards related to:
137     1.  Fiscal solvency.
138     2.  Quality of care.
139     3.  Adequacy of access to provider services.
140     4.  Specific requirements of the Medicaid program designed
141to meet the needs of the Medicaid recipients.
142     5.  The network's infrastructure capacity to manage
143financial transactions, recordkeeping, data collection, and
144other administrative functions.
145     6.  The network's ability to submit any financial,
146programmatic, or recipient encounter data or other information
147required by the agency to determine the actual services provided
148and the cost of administering the plan.
149     (d)  When the agency implements the system in an area of
150the state, the agency shall endeavor to provide recipients
151enrolled in the system with a choice of plans from qualified
152entities. The agency shall ensure that an entity operating a
153system, in addition to other requirements:
154     1.  Identifies the needs of the recipients using a
155standardized assessment process approved by the agency.
156     2.  Allows a recipient to select any provider that has a
157contract with the entity, provided that the service offered by
158the provider is appropriate to meet the needs of the recipient.
159     3.  Makes a good faith effort to develop contracts with
160qualified providers currently under contract with the Agency for
161Persons with Disabilities.
162     4.  Develops and uses a service provider qualification
163system approved by the agency that describes the quality of care
164standards that providers of services to persons with
165developmental disabilities must meet in order to obtain a
166contract with the plan entity.
167     5.  Excludes, when feasible, chronically poor-performing
168facilities and providers as determined by the agency.
169     6.  Demonstrates a quality assurance system and a
170performance improvement system that are satisfactory to the
172     (e)  The agency must ensure that the capitation-rate-
173setting methodology for the system is actuarially sound and
174reflects the intent to provide quality care in the least
175restrictive setting. The agency may choose to limit financial
176risk for entities operating the system to cover high-cost
177recipients or to address the catastrophic care needs of
178recipients enrolled in the system.
179     (f)  The system must provide that if the recipient resides
180in a noncontracted residential facility licensed under chapter
181393 or chapter 429 at the time of enrollment in the system, the
182recipient must be permitted to continue to reside in the
183noncontracted facility. The system must also provide that, in
184the absence of a contract between the system provider and the
185residential facility licensed under chapter 393 or chapter 429,
186the current Medicaid waiver rates must prevail.
187     (g)  Within 24 months after implementation, the agency
188shall contract for a comprehensive evaluation of the system. The
189evaluation must include assessments of cost savings, cost-
190effectiveness, recipient outcomes, consumer choice, access to
191services, coordination of care, and quality of care. The
192evaluation must describe administrative or legal barriers to the
193implementation and operation of the system and include
194recommendations regarding statewide expansion of the system. The
195agency shall submit its evaluation report to the Governor, the
196President of the Senate, and the Speaker of the House of
197Representatives no later than June 30, 2010.
198     (h)  The agency may seek federal waivers or Medicaid state
199plan amendments and adopt rules as necessary to administer the
200system on a pilot basis. The agency must receive specific
201authorization from the Legislature prior to expanding beyond the
202pilot areas designated for the implementation of the system.
203     Section 2.  This act shall take effect July 1, 2007.

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

Disclaimer: The information on this system is unverified. The journals or printed bills of the respective chambers should be consulted for official purposes. Copyright © 2000-2020 State of Florida.