Bill Text: FL H0267 | 2011 | Regular Session | Introduced
Bill Title: Nursing Home Diversion Program
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2011-05-07 - Indefinitely postponed and withdrawn from consideration [H0267 Detail]
Download: Florida-2011-H0267-Introduced.html
HB 267 |
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2 | An act relating to the nursing home diversion program; |
3 | amending s. 409.912, F.S.; directing the Agency for Health |
4 | Care Administration to expand the nursing home diversion |
5 | program to include Medicaid recipients who meet certain |
6 | criteria; specifying locations for phased-in |
7 | implementation of the program; revising conditions for |
8 | enrollment in the program; providing for Medicaid |
9 | recipient choice with regard to contractors; requiring the |
10 | nursing home diversion contractor to provide an enrollee |
11 | with information regarding alternative service providers; |
12 | requiring certain enrollees to participate in the program; |
13 | requiring the program to combine funding for Medicaid |
14 | services provided to specified individuals; removing an |
15 | exception; excluding specified individuals from |
16 | participation in the program; revising provisions relating |
17 | to entities eligible to participate in the program; |
18 | requiring the Department of Elderly Affairs and the agency |
19 | to seek federal waivers to limit the number of nursing |
20 | home diversion contractors in additional locations; |
21 | directing the agency to impose certain requirements on |
22 | contractors in the program; requiring the Office of |
23 | Program Policy Analysis and Government Accountability, in |
24 | consultation with the Auditor General, to evaluate the |
25 | nursing home diversion contractors in the program; |
26 | removing an obsolete provision relating to an |
27 | appropriation for implementation of a pilot program; |
28 | amending s. 408.040, F.S.; removing a reporting |
29 | requirement, to conform; providing an effective date. |
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31 | Be It Enacted by the Legislature of the State of Florida: |
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33 | Section 1. Subsection (5) of section 409.912, Florida |
34 | Statutes, is amended to read: |
35 | 409.912 Cost-effective purchasing of health care.-The |
36 | agency shall purchase goods and services for Medicaid recipients |
37 | in the most cost-effective manner consistent with the delivery |
38 | of quality medical care. To ensure that medical services are |
39 | effectively utilized, the agency may, in any case, require a |
40 | confirmation or second physician's opinion of the correct |
41 | diagnosis for purposes of authorizing future services under the |
42 | Medicaid program. This section does not restrict access to |
43 | emergency services or poststabilization care services as defined |
44 | in 42 C.F.R. part 438.114. Such confirmation or second opinion |
45 | shall be rendered in a manner approved by the agency. The agency |
46 | shall maximize the use of prepaid per capita and prepaid |
47 | aggregate fixed-sum basis services when appropriate and other |
48 | alternative service delivery and reimbursement methodologies, |
49 | including competitive bidding pursuant to s. 287.057, designed |
50 | to facilitate the cost-effective purchase of a case-managed |
51 | continuum of care. The agency shall also require providers to |
52 | minimize the exposure of recipients to the need for acute |
53 | inpatient, custodial, and other institutional care and the |
54 | inappropriate or unnecessary use of high-cost services. The |
55 | agency shall contract with a vendor to monitor and evaluate the |
56 | clinical practice patterns of providers in order to identify |
57 | trends that are outside the normal practice patterns of a |
58 | provider's professional peers or the national guidelines of a |
59 | provider's professional association. The vendor must be able to |
60 | provide information and counseling to a provider whose practice |
61 | patterns are outside the norms, in consultation with the agency, |
62 | to improve patient care and reduce inappropriate utilization. |
63 | The agency may mandate prior authorization, drug therapy |
64 | management, or disease management participation for certain |
65 | populations of Medicaid beneficiaries, certain drug classes, or |
66 | particular drugs to prevent fraud, abuse, overuse, and possible |
67 | dangerous drug interactions. The Pharmaceutical and Therapeutics |
68 | Committee shall make recommendations to the agency on drugs for |
69 | which prior authorization is required. The agency shall inform |
70 | the Pharmaceutical and Therapeutics Committee of its decisions |
71 | regarding drugs subject to prior authorization. The agency is |
72 | authorized to limit the entities it contracts with or enrolls as |
73 | Medicaid providers by developing a provider network through |
74 | provider credentialing. The agency may competitively bid single- |
75 | source-provider contracts if procurement of goods or services |
76 | results in demonstrated cost savings to the state without |
77 | limiting access to care. The agency may limit its network based |
78 | on the assessment of beneficiary access to care, provider |
79 | availability, provider quality standards, time and distance |
80 | standards for access to care, the cultural competence of the |
81 | provider network, demographic characteristics of Medicaid |
82 | beneficiaries, practice and provider-to-beneficiary standards, |
83 | appointment wait times, beneficiary use of services, provider |
84 | turnover, provider profiling, provider licensure history, |
85 | previous program integrity investigations and findings, peer |
86 | review, provider Medicaid policy and billing compliance records, |
87 | clinical and medical record audits, and other factors. Providers |
88 | shall not be entitled to enrollment in the Medicaid provider |
89 | network. The agency shall determine instances in which allowing |
90 | Medicaid beneficiaries to purchase durable medical equipment and |
91 | other goods is less expensive to the Medicaid program than long- |
92 | term rental of the equipment or goods. The agency may establish |
93 | rules to facilitate purchases in lieu of long-term rentals in |
94 | order to protect against fraud and abuse in the Medicaid program |
95 | as defined in s. 409.913. The agency may seek federal waivers |
96 | necessary to administer these policies. |
97 | (5) The Agency for Health Care Administration, in |
98 | partnership with the Department of Elderly Affairs, shall expand |
99 | the nursing home diversion program into |
100 | fixed-payment delivery program for all Medicaid recipients who |
101 | meet nursing home admission criteria and are 60 years of age or |
102 | older and |
103 | Agency for Health Care Administration shall implement the |
104 | integrated program initially in |
105 | 6, and 7 |
106 | 8, 9, 10, and 11 in 2013 and in Areas 1, 2, 3, and 4 in 2014. |
107 | All Medicaid recipients shall be given a choice of nursing home |
108 | diversion contractors in each area. In order to ensure enrollee |
109 | choice, when an enrollee is determined to be likely to require |
110 | the level of care provided in a hospital or nursing home, the |
111 | enrollee shall be informed by the nursing home diversion |
112 | contractor of any feasible alternatives available and given the |
113 | choice of either institutional or home and community-based |
114 | services |
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116 | shall be |
117 | federal waivers and this section. |
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128 | all funding for Medicaid services provided to individuals who |
129 | are 60 years of age or older and |
130 | and Medicaid into the integrated program, including funds for |
131 | Medicaid home and community-based waiver services; all Medicaid |
132 | services authorized in ss. 409.905 and 409.906, including |
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137 | persons dually eligible for Medicaid and Medicare as prescribed |
138 | in s. 409.908(13). |
139 | (a) Individuals who are 60 years of age or older, |
140 | dually eligible for Medicare and Medicaid, and enrolled in |
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148 | program. |
149 | (b) |
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154 | contractors |
155 | 430.703(6) and (7). The Department of Elderly Affairs and the |
156 | agency shall comply with s. 430.705(3) prior to approval of any |
157 | additional contractors |
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170 | (c) The agency must ensure that the capitation-rate- |
171 | setting methodology for the integrated program is actuarially |
172 | sound and reflects the intent to provide quality care in the |
173 | least restrictive setting. The agency must also require nursing |
174 | home diversion contractors |
175 | develop a credentialing system for service providers and to |
176 | contract with all Gold Seal nursing homes, where feasible, and |
177 | exclude, where feasible, chronically poor-performing facilities |
178 | and providers as defined by the agency. The integrated program |
179 | must develop and maintain an informal provider grievance system |
180 | that addresses provider payment and contract problems. The |
181 | agency shall also establish a formal grievance system to address |
182 | those issues that were not resolved through the informal |
183 | grievance system. The integrated program must provide that if |
184 | the recipient resides in a noncontracted residential facility |
185 | licensed under chapter 400 or chapter 429 at the time of |
186 | enrollment in the integrated program and the recipient's needs |
187 | cannot be met in a less restrictive environment, the recipient |
188 | must be permitted to continue to reside in the noncontracted |
189 | facility as long as the recipient desires. The integrated |
190 | program must also provide that, in the absence of a contract |
191 | between the nursing home diversion contractor |
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193 | or chapter 429, current Medicaid rates must prevail. The nursing |
194 | home diversion contractor |
195 | ensure that electronic nursing home claims that contain |
196 | sufficient information for processing are paid within 10 |
197 | business days after receipt. Alternately, the nursing home |
198 | diversion contractor |
199 | capitated payment mechanism to prospectively pay nursing homes |
200 | at the beginning of each month. The agency and the Department of |
201 | Elderly Affairs must jointly develop procedures to manage the |
202 | services provided through the integrated program in order to |
203 | ensure quality and recipient choice. |
204 | (d) The Office of Program Policy Analysis and Government |
205 | Accountability, in consultation with the Auditor General, shall |
206 | comprehensively evaluate |
207 | fixed-payment delivery program for Medicaid recipients created |
208 | under this subsection. The evaluation shall begin as soon as |
209 | Medicaid recipients are enrolled in the managed care |
210 | program plans and shall continue for 24 months thereafter. The |
211 | evaluation must include assessments of each nursing home |
212 | diversion contractor |
213 | with regard to cost savings; consumer education, choice, and |
214 | access to services; coordination of care; and quality of care. |
215 | The evaluation must describe administrative or legal barriers to |
216 | the implementation and operation of the |
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219 | the Governor, the President of the Senate, and the Speaker of |
220 | the House of Representatives no later than December 31, 2014 |
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222 | (e) The agency may seek federal waivers or Medicaid state |
223 | plan amendments and adopt rules as necessary to administer the |
224 | integrated program. The agency may implement the approved |
225 | federal waivers and other provisions as specified in this |
226 | subsection. |
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230 | Section 2. Paragraph (e) of subsection (1) of section |
231 | 408.040, Florida Statutes, is redesignated as paragraph (d), and |
232 | present paragraph (d) of that subsection is amended to read: |
233 | 408.040 Conditions and monitoring.- |
234 | (1) |
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255 | Section 3. This act shall take effect July 1, 2011. |
CODING: Words |