Florida Senate - 2011                      CS for CS for SB 1972
       
       
       
       By the Committees on Budget Subcommittee on Health and Human
       Services Appropriations; and Health Regulation; and Senators
       Negron, Gaetz, Garcia, and Hays
       
       
       603-03929-11                                          20111972c2
    1                        A bill to be entitled                      
    2         An act relating to health and human services; amending
    3         s. 163.387, F.S.; exempting hospital districts from
    4         the requirement to provide funding to a community
    5         redevelopment agency; creating s. 200.186, F.S.;
    6         requiring hospital district ad valorem revenues
    7         dispersed to other entities to be spent only on health
    8         care services; amending s. 393.0661, F.S.; conforming
    9         provisions to changes made by the act; amending s.
   10         409.016, F.S.; conforming provisions to changes made
   11         by the act; creating s. 409.16713, F.S.; providing for
   12         medical assistance for children in out-of-home care
   13         and adopted children; specifying how those services
   14         will be funded under certain circumstances; providing
   15         legislative intent; providing a directive to the
   16         Division of Statutory Revision; transferring,
   17         renumbering, and amending s. 624.91, F.S.; decreasing
   18         the administrative cost and raising the minimum loss
   19         ratio for health plans; increasing compensation to the
   20         insurer or provider for dental contracts; requiring
   21         the Florida Healthy Kids Corporation to include use of
   22         the school breakfast and lunch application form in the
   23         corporation’s plan for publicizing the program;
   24         conforming provisions to changes made by the act;
   25         amending ss. 409.813, 409.8132, 409.815, 409.818,
   26         154.503, and 408.915, F.S.; conforming provisions to
   27         changes made by the act; amending s. 1006.06, F.S.;
   28         requiring school districts to collaborate with the
   29         Florida Kidcare program to use the application form
   30         for the school breakfast and lunch programs to provide
   31         information about the Florida Kidcare program and to
   32         authorize data on the application form be shared with
   33         state agencies and the Florida Healthy Kids
   34         Corporation and its agents; authorizing each school
   35         district the option to share the data electronically;
   36         requiring interagency agreements to ensure that the
   37         data exchanged is protected from unauthorized
   38         disclosure and is used only for enrollment in the
   39         Florida Kidcare program; amending s. 409.901, F.S.;
   40         revising definitions relating to Medicaid; amending s.
   41         409.902, F.S.; revising provisions relating to the
   42         designation of the Agency for Health Care
   43         Administration as the state Medicaid agency;
   44         specifying that eligibility and state funds for
   45         medical services apply only to citizens and certain
   46         noncitizens; providing exceptions; providing a
   47         limitation on persons transferring assets in order to
   48         become eligible for certain services; amending s.
   49         409.9021, F.S.; revising provisions relating to
   50         conditions for Medicaid eligibility; increasing the
   51         number of years a Medicaid applicant forfeits
   52         entitlements to the Medicaid program if he or she has
   53         committed fraud; providing for the payment of monthly
   54         premiums by Medicaid recipients; providing exemptions
   55         to the premium requirement; requiring applicants to
   56         agree to participate in certain health programs;
   57         prohibiting a recipient who has access to employer
   58         sponsored health care from obtaining services
   59         reimbursed through the Medicaid fee-for-service
   60         system; requiring the agency to develop a process to
   61         allow the Medicaid premium that would have been
   62         received to be used to pay employer premiums;
   63         requiring that the agency allow opt-out opportunities
   64         for certain recipients; creating s. 409.9022, F.S.;
   65         specifying procedures to be implemented by a state
   66         agency if the Medicaid expenditures exceed
   67         appropriations; amending s. 409.903, F.S.; conforming
   68         provisions to changes made by the act; deleting
   69         obsolete provisions; amending s. 409.904, F.S.;
   70         conforming provisions to changes made by the act;
   71         renaming the “medically needy” program as the
   72         “Medicaid nonpoverty medical subsidy”; narrowing the
   73         subsidy to cover only certain services for a family,
   74         persons age 65 or older, or blind or disabled persons;
   75         revising the criteria for the agency’s assessment of
   76         need for private duty nursing services; amending s.
   77         409.905, F.S.; conforming provisions to changes made
   78         by the act; requiring prior authorization for home
   79         health services; amending s. 409.906, F.S.; providing
   80         for a parental fee based on family income to be
   81         assessed against the parents of children with
   82         developmental disabilities served by home and
   83         community-based waivers; prohibiting the agency from
   84         paying for certain psychotropic medications prescribed
   85         for a child; conforming provisions to changes made by
   86         the act; amending ss. 409.9062 and 409.907, F.S.;
   87         conforming provisions to changes made by the act;
   88         amending s. 409.908, F.S.; modifying the nursing home
   89         patient care per diem rate to include dental care,
   90         vision care, hearing care, and podiatric care;
   91         directing the agency to seek a waiver to treat a
   92         portion of the nursing home per diem as capital for
   93         self-insurance purposes; requiring primary physicians
   94         to be paid the Medicare fee-for-service rate by a
   95         certain date; deleting the requirement that the agency
   96         contract for transportation services with the
   97         community transportation system; authorizing qualified
   98         plans to contract for transportation services;
   99         deleting obsolete provisions; conforming provisions to
  100         changes made by the act; amending s. 409.9081, F.S.;
  101         revising copayments for physician visits; requiring
  102         the agency to seek a waiver to allow the increase of
  103         copayments for nonemergency services furnished in a
  104         hospital emergency department; amending s. 409.912,
  105         F.S.; requiring Medicaid-eligible children who have
  106         open child welfare cases and who reside in AHCA area
  107         10 to be enrolled in specified capitated managed care
  108         plans; expanding the number of children eligible to
  109         receive behavioral health care services through a
  110         specialty prepaid plan; repealing provisions relating
  111         to a provider lock-in program; eliminating obsolete
  112         provisions and updating provisions; conforming cross
  113         references; amending s. 409.915, F.S.; conforming
  114         provisions to changes made by the act; transferring,
  115         renumbering, and amending s. 409.9301, F.S.;
  116         conforming provisions to changes made by the act;
  117         amending s. 409.9126, F.S.; conforming a cross
  118         reference; providing a directive to the Division of
  119         Statutory Revision; creating s. 409.961, F.S.;
  120         providing for statutory construction of provisions
  121         relating to Medicaid managed care; creating s.
  122         409.962, F.S.; providing definitions; creating s.
  123         409.963, F.S.; establishing the Medicaid managed care
  124         program as the statewide, integrated managed care
  125         program for medical assistance and long-term care
  126         services; directing the agency to apply for and
  127         implement waivers; providing for public notice and
  128         comment; providing for a limited managed care program
  129         if waivers are not approved; creating s. 409.964,
  130         F.S.; requiring all Medicaid recipients to be enrolled
  131         in Medicaid managed care; providing exemptions;
  132         prohibiting a recipient who has access to employer
  133         sponsored health care from enrolling in Medicaid
  134         managed care; requiring the agency to develop a
  135         process to allow the Medicaid premium that would have
  136         been received to be used to pay employer premiums;
  137         requiring that the agency allow opt-out opportunities
  138         for certain recipients; providing for voluntary
  139         enrollment; creating s. 409.965, F.S.; providing
  140         requirements for qualified plans that provide services
  141         in the Medicaid managed care program; requiring the
  142         agency to issue an invitation to negotiate; requiring
  143         the agency to compile and publish certain information;
  144         establishing regions for separate procurement of
  145         plans; establishing selection criteria for plan
  146         selection; limiting the number of plans in a region;
  147         authorizing the agency to conduct negotiations if
  148         funding is insufficient; specifying circumstances
  149         under which the agency may issue a new invitation to
  150         negotiate; providing that the Children’s Medical
  151         Service Network is a qualified plan; directing the
  152         agency to assign Medicaid provider agreements for a
  153         limited time to a provider services network
  154         participating in the managed care program in a rural
  155         area; creating s. 409.966, F.S.; providing managed
  156         care plan contract requirements; establishing contract
  157         terms; providing for annual rate setting; providing
  158         for contract extension under certain circumstances;
  159         establishing access requirements; requiring the agency
  160         to establish performance standards for plans;
  161         requiring each plan to publish specified measures on
  162         the plan’s website; providing for program integrity;
  163         requiring plans to provide encounter data; providing
  164         penalties for failure to submit data; requiring plans
  165         to accept electronic claims and electronic prior
  166         authorization requests for medication exceptions;
  167         requiring plans to provide the criteria for approval
  168         and reasons for denial of prior authorization
  169         requests; providing for prompt payment; providing for
  170         payments to noncontract emergency providers; requiring
  171         a qualified plan to post a surety bond or establish a
  172         letter of credit or a deposit in a trust account;
  173         requiring plans to establish a grievance resolution
  174         process; requiring plan solvency; requiring guaranteed
  175         savings; providing costs and penalties for early
  176         termination of contracts or reduction in enrollment
  177         levels; requiring the agency to terminate qualified
  178         plans for noncompliance under certain circumstances;
  179         requiring plans to adopt and publish a preferred drug
  180         list; creating s. 409.967, F.S.; providing for managed
  181         care plan accountability; requiring plans to use a
  182         uniform method of accounting for medical costs;
  183         providing for achieved savings rebates; authorizing
  184         plans to limit providers in networks; mandating that
  185         certain providers be offered contracts during the
  186         first year; authorizing plans to exclude certain
  187         providers in certain circumstances; requiring plans to
  188         include certain providers; requiring plans to monitor
  189         the quality and performance history of providers;
  190         requiring plans to hold primary care physicians
  191         responsible for certain activities; requiring plans to
  192         offer certain programs and procedures; requiring plans
  193         to pay primary care providers the same rate as
  194         Medicare by a certain date; providing for conflict
  195         resolution between plans and providers; creating s.
  196         409.968, F.S.; providing for managed care plan
  197         payments on a per-member, per-month basis; requiring
  198         the agency to establish a methodology to ensure the
  199         availability of certain types of payments to specified
  200         providers; requiring the development of rate cells;
  201         requiring that the amount paid to the plans for
  202         supplemental payments or enhanced rates be reconciled
  203         to the amount required to pay providers; requiring
  204         that plans make certain payments to providers within a
  205         certain time; requiring the agency to develop a
  206         methodology and request a state plan amendment to
  207         ensure the availability of certified public
  208         expenditures in the Medicaid managed care program to
  209         support certain noninstitutional teaching faculty
  210         providers; creating s. 409.969, F.S.; authorizing
  211         Medicaid recipients to select any plan within a
  212         region; providing for automatic enrollment of
  213         recipients by the agency in specified circumstances;
  214         providing criteria for automatic enrollment;
  215         authorizing disenrollment under certain circumstances;
  216         providing for a grievance process; defining the term
  217         “good cause” for purposes of disenrollment; requiring
  218         recipients to stay in plans for a specified time;
  219         providing for reenrollment of recipients who move out
  220         of a region; creating s. 409.970, F.S.; requiring the
  221         agency to maintain an encounter data system; providing
  222         requirements for prepaid plans to submit data in a
  223         certain format; requiring the agency to analyze the
  224         data; requiring the agency to test the data for
  225         certain purposes by a certain date; creating s.
  226         409.971, F.S.; providing for managed care medical
  227         assistance; providing deadlines for beginning and
  228         finalizing implementation; creating s. 409.972, F.S.;
  229         establishing minimum services for the managed medical
  230         assistance; providing for optional services;
  231         authorizing plans to customize benefit packages;
  232         requiring the agency to provide certain services to
  233         hemophiliacs; creating s. 409.973, F.S.; providing for
  234         managed long-term care; providing deadlines for
  235         beginning and finalizing implementation; providing
  236         duties for the Department of Elderly Affairs relating
  237         to the program; creating s. 409.974, F.S.; providing
  238         recipient eligibility requirements for managed long
  239         term care; listing programs for which certain
  240         recipients are eligible; specifying that an
  241         entitlement to home and community-based services is
  242         not created; creating s. 409.975, F.S.; establishing
  243         minimum services for managed long-term care; creating
  244         s. 409.976, F.S.; providing criteria for the selection
  245         of plans to provide managed long-term care; creating
  246         s. 409.977, F.S.; providing for managed long-term care
  247         plan accountability; requiring the agency to establish
  248         standards for specified providers; creating s.
  249         409.978, F.S.; requiring that the agency operate the
  250         Comprehensive Assessment and Review for Long-Term Care
  251         Services program through an interagency agreement with
  252         the Department of Elderly Affairs; providing duties of
  253         the program; requiring the program to assign plan
  254         enrollees to a level of care; providing for the
  255         evaluation of dually eligible nursing home residents;
  256         transferring, renumbering, and amending ss. 409.91207,
  257         409.91211, and 409.9122, F.S.; conforming provisions
  258         to changes made by the act; updating provisions and
  259         deleting obsolete provisions; transferring and
  260         renumbering ss. 409.9123 and 409.9124, F.S.; amending
  261         s. 430.04, F.S.; eliminating outdated provisions;
  262         requiring the Department of Elderly Affairs to develop
  263         a transition plan for specified elders and disabled
  264         adults receiving long-term care Medicaid services if
  265         qualified plans become available; amending s.
  266         430.2053, F.S.; eliminating outdated provisions;
  267         providing additional duties of aging resource centers;
  268         providing an additional exception to direct services
  269         that may not be provided by an aging resource center;
  270         providing for the cessation of specified payments by
  271         the department as qualified plans become available;
  272         eliminating provisions requiring reports; amending s.
  273         39.407, F.S.; requiring a motion by the Department of
  274         Children and Family Services to provide psychotropic
  275         medication to a child 10 years of age or younger to
  276         include a review by a child psychiatrist; providing
  277         that a court may not authorize the administration of
  278         such medication absent a finding of compelling state
  279         interest based on the review; amending s. 216.262,
  280         F.S.; providing that limitations on an agency’s total
  281         number of positions does not apply to certain
  282         positions in the Department of Health; amending s.
  283         381.06014, F.S.; redefining the term “blood
  284         establishment” and defining the term “volunteer
  285         donor”; requiring that blood establishments disclose
  286         specified information on their Internet website;
  287         providing an exception for certain hospitals;
  288         authorizing the Department of Legal Affairs to assess
  289         a civil penalty against a blood establishment that
  290         fails to disclose the information; providing that the
  291         civil penalty accrues to the state and requiring that
  292         it be deposited into the General Revenue Fund;
  293         prohibiting local governments from restricting access
  294         to public facilities or infrastructure for certain
  295         activities based on whether a blood establishment is
  296         operating as a for-profit or not-for-profit
  297         organization; prohibiting a blood establishment from
  298         considering whether certain customers are operating as
  299         for-profit or not-for-profit organizations when
  300         determining service fees for blood or blood
  301         components; amending s. 400.023, F.S.; requiring the
  302         trial judge to conduct an evidentiary hearing to
  303         determine the sufficiency of evidence for claims
  304         against certain persons relating to a nursing home;
  305         limiting noneconomic damages in a wrongful death
  306         action against the nursing home; amending s. 400.0237,
  307         F.S.; revising provisions relating to punitive damages
  308         against a nursing home; authorizing a defendant to
  309         proffer admissible evidence to refute a claimant’s
  310         proffer of evidence for punitive damages; requiring
  311         the trial judge to conduct an evidentiary hearing and
  312         the plaintiff to demonstrate that a reasonable basis
  313         exists for the recovery of punitive damages;
  314         prohibiting discovery of the defendant’s financial
  315         worth until the judge approves the pleading on
  316         punitive damages; revising definitions; amending s.
  317         408.7057, F.S.; requiring that the dispute resolution
  318         program include a hearing in specified circumstances;
  319         providing that the dispute resolution program
  320         established to resolve claims disputes between
  321         providers and health plans does not provide an
  322         independent right of recovery; requiring that the
  323         conclusions of law in the written recommendation of
  324         the resolution organization identify certain
  325         information; providing a directive to the Division of
  326         Statutory Revision; creating ss. 458.3167 and
  327         459.0078, F.S.; providing for an expert witness
  328         certificate for allopathic and osteopathic physicians
  329         licensed in other states or Canada which authorizes
  330         such physicians to provide expert medical opinions in
  331         this state; providing application requirements and
  332         timeframes for approval or denial by the Board of
  333         Medicine and Board of Osteopathic Medicine,
  334         respectively; requiring the boards to adopt rules and
  335         set fees; providing for expiration of a certificate;
  336         amending ss. 458.331 and 459.015, F.S.; providing
  337         grounds for disciplinary action for providing
  338         misleading, deceptive, or fraudulent expert witness
  339         testimony relating to the practice of medicine and of
  340         osteopathic medicine, respectively; providing for
  341         construction with respect to the doctrine of
  342         incorporation by reference; amending s. 499.003, F.S.;
  343         redefining the term “health care entity” to clarify
  344         that a blood establishment is a health care entity
  345         that may engage in certain activities; amending s.
  346         499.005, F.S.; clarifying provisions that prohibit the
  347         unauthorized wholesale distribution of a prescription
  348         drug that was purchased by a hospital or other health
  349         care entity or donated or supplied at a reduced price
  350         to a charitable organization, to conform to changes
  351         made by the act; amending s. 499.01, F.S.; exempting
  352         certain blood establishments from the requirements to
  353         be permitted as a prescription drug manufacturer and
  354         register products; requiring that certain blood
  355         establishments obtain a restricted prescription drug
  356         distributor permit under specified conditions;
  357         limiting the prescription drugs that a blood
  358         establishment may distribute under a restricted
  359         prescription drug distributor permit; authorizing the
  360         Department of Health to adopt rules regarding the
  361         distribution of prescription drugs by blood
  362         establishments; amending s. 626.9541, F.S.;
  363         authorizing insurers to offer rewards or incentives to
  364         health benefit plan members to encourage or reward
  365         participation in wellness or health improvement
  366         programs; authorizing insurers to require plan members
  367         not participating in programs to provide verification
  368         that their medical condition warrants
  369         nonparticipation; providing application; amending s.
  370         627.4147, F.S.; deleting a requirement that a medical
  371         malpractice insurance contract include a clause
  372         authorizing an insurer to admit liability and make a
  373         settlement offer if the offer is within policy limits
  374         without the insured’s permission; amending s. 766.102,
  375         F.S.; providing that a physician who is an expert
  376         witness in a medical malpractice presuit action must
  377         meet certain requirements; amending s. 766.104, F.S.;
  378         requiring a good faith demonstration in a medical
  379         malpractice case that there has been a breach of the
  380         standard of care; amending s. 766.106, F.S.;
  381         clarifying that a physician acting as an expert
  382         witness is subject to disciplinary actions; amending
  383         s. 766.1115, F.S.; conforming provisions to changes
  384         made by the act; creating s. 766.1183, F.S.; defining
  385         terms; providing for the recovery of civil damages by
  386         Medicaid recipients according to a modified standard
  387         of care; providing for recovery of certain excess
  388         judgments by act of the Legislature; requiring the
  389         Department of Children and Family Services to provide
  390         notice to program applicants; creating s. 766.1184,
  391         F.S.; defining terms; providing for the recovery of
  392         civil damages by certain recipients of primary care
  393         services at primary care clinics receiving specified
  394         low-income pool funds according to a modified standard
  395         of care; providing for recovery of certain excess
  396         judgments by act of the Legislature; providing
  397         requirements of health care providers receiving such
  398         funds in order for the liability provisions to apply;
  399         requiring notice to low-income pool recipients;
  400         amending s. 766.203, F.S.; requiring the presuit
  401         investigations conducted by the claimant and the
  402         prospective defendant in a medical malpractice action
  403         to provide grounds for a breach of the standard of
  404         care; amending s. 768.28, F.S.; revising a definition;
  405         providing that certain colleges and universities that
  406         own or operate an accredited medical school and their
  407         employees and agents providing patient services in a
  408         teaching hospital pursuant to an affiliation agreement
  409         or contract with the teaching hospital are considered
  410         agents of the hospital for the purposes of sovereign
  411         immunity; providing definitions; requiring patients of
  412         such hospitals to be provided with notice of their
  413         remedies under sovereign immunity; providing an
  414         exception; providing that providers and vendors
  415         providing services to certain persons with
  416         disabilities on behalf of the state are agents of the
  417         state for the purposes of sovereign immunity;
  418         providing legislative findings and intent with respect
  419         to including certain colleges and universities and
  420         their employees and agents under sovereign immunity;
  421         providing a statement of public necessity; amending s.
  422         1004.41, F.S.; clarifying provisions relating to
  423         references to the corporation known as Shands Teaching
  424         Hospital and Clinics, Inc.; clarifying provisions
  425         regarding the purpose of the corporation; authorizing
  426         the corporation to create corporate subsidiaries and
  427         affiliates; providing that Shands Teaching Hospital
  428         and Clinics, Inc., Shands Jacksonville Medical Center,
  429         Inc., Shands Jacksonville Healthcare, Inc., and any
  430         not-for-profit subsidiary of such entities are
  431         instrumentalities of the state for purposes of
  432         sovereign immunity; repealing s. 409.9121, F.S.,
  433         relating to legislative intent concerning managed
  434         care; repealing s. 409.919, F.S., relating to rule
  435         authority; repealing s. 624.915, F.S., relating to the
  436         Florida Healthy Kids Corporation operating fund;
  437         renumbering and transferring ss. 409.942, 409.944,
  438         409.945, 409.946, 409.953, and 409.9531, F.S., as ss.
  439         414.29, 163.464, 163.465, 163.466, 402.81, and 402.82,
  440         F.S., respectively; amending s. 443.111, F.S.;
  441         conforming a cross-reference; directing the Agency for
  442         Health Care Administration to submit a reorganization
  443         plan to the Legislature; providing for the state’s
  444         withdrawal from the Medicaid program under certain
  445         circumstances; providing for severability; providing
  446         an effective date.
  447  
  448  Be It Enacted by the Legislature of the State of Florida:
  449  
  450         Section 1. Paragraph (c) of subsection (2) of section
  451  163.387, Florida Statutes, is amended to read:
  452         163.387 Redevelopment trust fund.—
  453         (2)
  454         (c) The following public bodies or taxing authorities are
  455  exempt from paragraph (a):
  456         1. A special district that levies ad valorem taxes on
  457  taxable real property in more than one county.
  458         2. A special district for which the sole available source
  459  of revenue the district has the authority to levy is ad valorem
  460  taxes at the time an ordinance is adopted under this section.
  461  However, revenues or aid that may be dispensed or appropriated
  462  to a district as defined in s. 388.011 at the discretion of an
  463  entity other than such district shall not be deemed available.
  464         3. A library district, except a library district in a
  465  jurisdiction where the community redevelopment agency had
  466  validated bonds as of April 30, 1984.
  467         4. A neighborhood improvement district created under the
  468  Safe Neighborhoods Act.
  469         5. A metropolitan transportation authority.
  470         6. A water management district created under s. 373.069.
  471         7. A hospital district that is a special district as
  472  defined in s. 189.403, a county hospital that has taxing
  473  authority under chapter 155, or a public health trust
  474  established pursuant to s. 154.07.
  475         Section 2. Section 200.186, Florida Statutes, is created to
  476  read:
  477         200.186Hospital districts.—Notwithstanding any special act
  478  or other law governing the expenditure of ad valorem revenues,
  479  ad valorem revenues raised pursuant to a special act
  480  establishing a hospital district, by a county hospital pursuant
  481  to chapter 155, or a public health trust established pursuant to
  482  s. 154.07, and disbursed by the district, county hospital, or
  483  trust to municipalities or other organizations, may be used only
  484  to pay for health care services.
  485         Section 3. Present subsections (7) and (8) of section
  486  393.0661, Florida Statutes, are redesignated as subsections (8)
  487  and (9), respectively, a new subsection (7) is added to that
  488  section, and present subsection (7) of that section is amended,
  489  to read:
  490         393.0661 Home and community-based services delivery system;
  491  comprehensive redesign.—The Legislature finds that the home and
  492  community-based services delivery system for persons with
  493  developmental disabilities and the availability of appropriated
  494  funds are two of the critical elements in making services
  495  available. Therefore, it is the intent of the Legislature that
  496  the Agency for Persons with Disabilities shall develop and
  497  implement a comprehensive redesign of the system.
  498         (7) The agency shall impose and collect the fee authorized
  499  by s. 409.906(13)(d) upon approval by the Centers for Medicare
  500  and Medicaid Services.
  501         (8)(7)Nothing in This section or related in any
  502  administrative rule does not shall be construed to prevent or
  503  limit the Agency for Health Care Administration, in consultation
  504  with the Agency for Persons with Disabilities, from adjusting
  505  fees, reimbursement rates, lengths of stay, number of visits, or
  506  number of services, or from limiting enrollment, or making any
  507  other adjustment necessary to comply with the availability of
  508  moneys and any limitations or directions provided for in the
  509  General Appropriations Act or pursuant to s. 409.9022.
  510         Section 4. The Division of Statutory Revision is requested
  511  to designate ss. 409.016-409.803, Florida Statutes, as part I of
  512  chapter 409, Florida Statutes, entitled “SOCIAL AND ECONOMIC
  513  ASSISTANCE.
  514         Section 5. Section 409.016, Florida Statutes, is amended to
  515  read:
  516         409.016 Definitions.—As used in this part, the term
  517  chapter:
  518         (1) “Department,unless otherwise specified, means the
  519  Department of Children and Family Services.
  520         (2) “Secretary” means the Secretary of the Department of
  521  Children and Family Services.
  522         (3) “Social and economic services,within the meaning of
  523  this chapter, means the providing of financial assistance as
  524  well as preventive and rehabilitative social services for
  525  children, adults, and families.
  526         Section 6. Section 409.16713, Florida Statutes, is created
  527  to read:
  528         409.16713 Medical assistance for children in out-of-home
  529  care and adopted children.—
  530         (1) A child who is eligible under Title IV-E of the Social
  531  Security Act, as amended, for subsidized board payments, foster
  532  care, or adoption subsidies, and a child for whom the state has
  533  assumed temporary or permanent responsibility and who does not
  534  qualify for Title IV-E assistance but is in foster care, shelter
  535  or emergency shelter care, or subsidized adoption is eligible
  536  for medical assistance as provided in s. 409.903(4). This
  537  includes a young adult who is eligible to receive services under
  538  s. 409.1451(5) until the young adult reaches 21 years of age,
  539  and a person who was eligible, as a child, under Title IV-E for
  540  foster care or the state-provided foster care and who is a
  541  participant in the Road-to-Independence Program.
  542         (2) If medical assistance under Title XIX of the Social
  543  Security Act, as amended, is not available due to the refusal of
  544  the federal Department of Health and Human Services to provide
  545  federal funds, a child or young adult described in subsection
  546  (1) is eligible for medical services under the Medicaid managed
  547  care program established in s. 409.963. Such medical assistance
  548  shall be obtained by the community-based care lead agencies
  549  established under s. 409.1671 and is subject to the availability
  550  of funds appropriated for such purpose in the General
  551  Appropriations Act.
  552         (3) It is the intent of the Legislature that the provision
  553  of medical assistance meet the requirements of s. 471(a)(21) of
  554  the Social Security Act, as amended, 42 U.S.C. s. 671(a)(21),
  555  related to eligibility for Title IV-E of the Social Security
  556  Act, and that compliance with such provisions meet the
  557  requirements of s. 402(a)(3) of the Social Security Act, as
  558  amended, 42 U.S.C. s. 602(a)(3), relating to the Temporary
  559  Assistance for Needy Families Block Grant Program.
  560         Section 7. The Division of Statutory Revision is requested
  561  to designate ss. 409.810-409.821, Florida Statutes, as part II
  562  of chapter 409, Florida Statutes, entitled “KIDCARE.
  563         Section 8. Section 624.91, Florida Statutes, is
  564  transferred, renumbered as section 409.8115, Florida Statutes,
  565  paragraph (b) of subsection (5) of that section is amended, and
  566  subsection (8) is added to that section, to read:
  567         409.8115 624.91 The Florida Healthy Kids Corporation Act.—
  568         (5) CORPORATION AUTHORIZATION, DUTIES, POWERS.—
  569         (b) The Florida Healthy Kids Corporation shall:
  570         1. Arrange for the collection of any family, local
  571  contributions, or employer payment or premium, in an amount to
  572  be determined by the board of directors, to provide for payment
  573  of premiums for comprehensive insurance coverage and for the
  574  actual or estimated administrative expenses.
  575         2. Arrange for the collection of any voluntary
  576  contributions to provide for payment of Florida Kidcare program
  577  premiums for children who are not eligible for medical
  578  assistance under Title XIX or Title XXI of the Social Security
  579  Act.
  580         3. Subject to the provisions of s. 409.8134, accept
  581  voluntary supplemental local match contributions that comply
  582  with the requirements of Title XXI of the Social Security Act
  583  for the purpose of providing additional Florida Kidcare coverage
  584  in contributing counties under Title XXI.
  585         4. Establish the administrative and accounting procedures
  586  for the operation of the corporation.
  587         5. Establish, with consultation from appropriate
  588  professional organizations, standards for preventive health
  589  services and providers and comprehensive insurance benefits
  590  appropriate to children if, provided that such standards for
  591  rural areas do shall not limit primary care providers to board
  592  certified pediatricians.
  593         6. Determine eligibility for children seeking to
  594  participate in the Title XXI-funded components of the Florida
  595  Kidcare program consistent with the requirements specified in s.
  596  409.814, as well as the non-Title-XXI-eligible children as
  597  provided in subsection (3).
  598         7. Establish procedures under which providers of local
  599  match to, applicants to, and participants in the program may
  600  have grievances reviewed by an impartial body and reported to
  601  the board of directors of the corporation.
  602         8. Establish participation criteria and, if appropriate,
  603  contract with an authorized insurer, health maintenance
  604  organization, or third-party administrator to provide
  605  administrative services to the corporation.
  606         9. Establish enrollment criteria that include penalties or
  607  30-day waiting periods of 30 days for reinstatement of coverage
  608  upon voluntary cancellation for nonpayment of family premiums.
  609         10. Contract with authorized insurers or providers any
  610  provider of health care services, who meet meeting standards
  611  established by the corporation, for the provision of
  612  comprehensive insurance coverage to participants. Such standards
  613  must shall include criteria under which the corporation may
  614  contract with more than one provider of health care services in
  615  program sites. Health plans shall be selected through a
  616  competitive bid process. The Florida Healthy Kids Corporation
  617  shall purchase goods and services in the most cost-effective
  618  manner consistent with the delivery of quality medical care. The
  619  maximum administrative cost for a Florida Healthy Kids
  620  Corporation contract shall be 10 15 percent. For health care
  621  contracts, the minimum medical loss ratio for a Florida Healthy
  622  Kids Corporation contract shall be 90 85 percent. For dental
  623  contracts, the remaining compensation to be paid to the
  624  authorized insurer or provider must be at least 90 under a
  625  Florida Healthy Kids Corporation contract shall be no less than
  626  an amount which is 85 percent of the premium, and; to the extent
  627  any contract provision does not provide for this minimum
  628  compensation, this section prevails shall prevail. The health
  629  plan selection criteria and scoring system, and the scoring
  630  results, shall be available upon request for inspection after
  631  the bids have been awarded.
  632         11. Establish disenrollment criteria if in the event local
  633  matching funds are insufficient to cover enrollments.
  634         12. Develop and implement a plan to publicize the Florida
  635  Kidcare program, the eligibility requirements of the program,
  636  and the procedures for enrollment in the program and to maintain
  637  public awareness of the corporation and the program. Such plan
  638  must include using the application form for the school lunch and
  639  breakfast programs as provided under s. 1006.06(7).
  640         13. Secure staff necessary to properly administer the
  641  corporation. Staff costs shall be funded from state and local
  642  matching funds and such other private or public funds as become
  643  available. The board of directors shall determine the number of
  644  staff members necessary to administer the corporation.
  645         14. In consultation with the partner agencies, provide an
  646  annual a report on the Florida Kidcare program annually to the
  647  Governor, the Chief Financial Officer, the Commissioner of
  648  Education, the President of the Senate, the Speaker of the House
  649  of Representatives, and the Minority Leaders of the Senate and
  650  the House of Representatives.
  651         15. Provide information on a quarterly basis to the
  652  Legislature and the Governor which compares the costs and
  653  utilization of the full-pay enrolled population and the Title
  654  XXI-subsidized enrolled population in the Florida Kidcare
  655  program. The information, At a minimum, the information must
  656  include:
  657         a. The monthly enrollment and expenditure for full-pay
  658  enrollees in the Medikids and Florida Healthy Kids programs
  659  compared to the Title XXI-subsidized enrolled population; and
  660         b. The costs and utilization by service of the full-pay
  661  enrollees in the Medikids and Florida Healthy Kids programs and
  662  the Title XXI-subsidized enrolled population.
  663  
  664  By February 1, 2010, the Florida Healthy Kids Corporation shall
  665  provide a study to the Legislature and the Governor on premium
  666  impacts to the subsidized portion of the program from the
  667  inclusion of the full-pay program, which must shall include
  668  recommendations on how to eliminate or mitigate possible impacts
  669  to the subsidized premiums.
  670         16. Establish benefit packages that conform to the
  671  provisions of the Florida Kidcare program, as created under this
  672  part in ss. 409.810-409.821.
  673         (8) OPERATING FUND.—The Florida Healthy Kids Corporation
  674  may establish and manage an operating fund for the purposes of
  675  addressing the corporation’s unique cash-flow needs and
  676  facilitating the fiscal management of the corporation. At any
  677  given time, the corporation may accumulate and maintain in the
  678  operating fund a cash balance reserve equal to no more than 25
  679  percent of its annualized operating expenses. Upon dissolution
  680  of the corporation, any remaining cash balances of state funds
  681  shall revert to the General Revenue Fund, or such other state
  682  funds consistent with the appropriated funding, as provided by
  683  law.
  684         Section 9. Subsection (1) of section 409.813, Florida
  685  Statutes, is amended to read:
  686         409.813 Health benefits coverage; program components;
  687  entitlement and nonentitlement.—
  688         (1) The Florida Kidcare program includes health benefits
  689  coverage provided to children through the following program
  690  components, which shall be marketed as the Florida Kidcare
  691  program:
  692         (a) Medicaid.;
  693         (b) Medikids as created in s. 409.8132.;
  694         (c) The Florida Healthy Kids Corporation as created in s.
  695  409.8115. 624.91;
  696         (d) Employer-sponsored group health insurance plans
  697  approved under this part. ss. 409.810-409.821; and
  698         (e) The Children’s Medical Services network established in
  699  chapter 391.
  700         Section 10. Subsection (4) of section 409.8132, Florida
  701  Statutes, is amended to read:
  702         409.8132 Medikids program component.—
  703         (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.—The
  704  provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
  705  409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
  706  409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205,
  707  409.987, 409.988, and 409.989 apply to the administration of the
  708  Medikids program component of the Florida Kidcare program,
  709  except that s. 409.987 409.9122 applies to Medikids as modified
  710  by the provisions of subsection (7).
  711         Section 11. Subsection (1) of section 409.815, Florida
  712  Statutes, is amended to read:
  713         409.815 Health benefits coverage; limitations.—
  714         (1) MEDICAID BENEFITS.—For purposes of the Florida Kidcare
  715  program, benefits available under Medicaid and Medikids include
  716  those goods and services provided under the medical assistance
  717  program authorized by Title XIX of the Social Security Act, and
  718  regulations thereunder, as administered in this state by the
  719  agency. This includes those mandatory Medicaid services
  720  authorized under s. 409.905 and optional Medicaid services
  721  authorized under s. 409.906, rendered on behalf of eligible
  722  individuals by qualified providers, in accordance with federal
  723  requirements for Title XIX, subject to any limitations or
  724  directions provided for in the General Appropriations Act, or
  725  chapter 216, or s. 409.9022, and according to methodologies and
  726  limitations set forth in agency rules and policy manuals and
  727  handbooks incorporated by reference thereto.
  728         Section 12. Subsection (5) of section 409.818, Florida
  729  Statutes, is amended to read:
  730         409.818 Administration.—In order to implement ss. 409.810
  731  409.821, the following agencies shall have the following duties:
  732         (5) The Florida Healthy Kids Corporation shall retain its
  733  functions as authorized in s. 409.8115 624.91, including
  734  eligibility determination for participation in the Healthy Kids
  735  program.
  736         Section 13. Paragraph (e) of subsection (2) of section
  737  154.503, Florida Statutes, is amended to read:
  738         154.503 Primary Care for Children and Families Challenge
  739  Grant Program; creation; administration.—
  740         (2) The department shall:
  741         (e) Coordinate with the primary care program developed
  742  pursuant to s. 154.011, the Florida Healthy Kids Corporation
  743  program created in s. 409.8115 624.91, the school health
  744  services program created in ss. 381.0056 and 381.0057, the
  745  Healthy Communities, Healthy People Program created in s.
  746  381.734, and the volunteer health care provider program
  747  established developed pursuant to s. 766.1115.
  748         Section 14. Paragraph (c) of subsection (4) of section
  749  408.915, Florida Statutes, is amended to read:
  750         408.915 Eligibility pilot project.—The Agency for Health
  751  Care Administration, in consultation with the steering committee
  752  established in s. 408.916, shall develop and implement a pilot
  753  project to integrate the determination of eligibility for health
  754  care services with information and referral services.
  755         (4) The pilot project shall include eligibility
  756  determinations for the following programs:
  757         (c) Florida Healthy Kids as described in s. 409.8115 624.91
  758  and within eligibility guidelines provided in s. 409.814.
  759         Section 15. Subsection (7) is added to section 1006.06,
  760  Florida Statutes, to read:
  761         1006.06 School food service programs.—
  762         (7)Each school district shall collaborate with the Florida
  763  Kidcare program created pursuant to ss. 409.810-409.821 to:
  764         (a)At a minimum:
  765         1.Provide application information about the Kidcare
  766  program or an application for Kidcare to students at the
  767  beginning of each school year.
  768         2.Modify the school district’s application form for the
  769  lunch program under subsection (4) and the breakfast program
  770  under subsection (5) to incorporate a provision that permits the
  771  school district to share data from the application form with the
  772  state agencies and the Florida Healthy Kids Corporation and its
  773  agents that administer the Kidcare program unless the child’s
  774  parent or guardian opts out of the provision.
  775         (b)At the option of the school district, share income and
  776  other demographic data through an electronic interchange with
  777  the Florida Healthy Kids Corporation and other state agencies in
  778  order to determine eligibility for the Kidcare program on a
  779  regular and periodic basis.
  780         (c)Establish interagency agreements ensuring that data
  781  exchanged under this subsection is used only to enroll eligible
  782  children in the Florida Kidcare program and is protected from
  783  unauthorized disclosure pursuant to 42 U.S.C. s. 1758(b)(6).
  784         Section 16. The Division of Statutory Revision is requested
  785  to designate ss. 409.901 through 409.9205, Florida Statutes, as
  786  part III of chapter 409, Florida Statutes, entitled “MEDICAID.
  787         Section 17. Section 409.901, Florida Statutes, is amended
  788  to read:
  789         409.901 Definitions; ss. 409.901-409.920.—As used in this
  790  part and part IV ss. 409.901-409.920, except as otherwise
  791  specifically provided, the term:
  792         (1) “Affiliate” or “affiliated person” means any person who
  793  directly or indirectly manages, controls, or oversees the
  794  operation of a corporation or other business entity that is a
  795  Medicaid provider, regardless of whether such person is a
  796  partner, shareholder, owner, officer, director, agent, or
  797  employee of the entity.
  798         (2) “Agency” means the Agency for Health Care
  799  Administration. The agency is the Medicaid agency for the state,
  800  as provided under federal law.
  801         (3) “Applicant” means an individual whose written
  802  application for medical assistance provided by Medicaid under
  803  ss. 409.903-409.906 has been submitted to the Department of
  804  Children and Family Services, or to the Social Security
  805  Administration if the application is for Supplemental Security
  806  Income, but has not received final action. The This term
  807  includes an individual, who need not be alive at the time of
  808  application, and whose application is submitted through a
  809  representative or a person acting for the individual.
  810         (4) “Benefit” means any benefit, assistance, aid,
  811  obligation, promise, debt, liability, or the like, related to
  812  any covered injury, illness, or necessary medical care, goods,
  813  or services.
  814         (5) “Capitation” means a prospective per-member, per-month
  815  payment designed to represent, in the aggregate, an actuarially
  816  sound estimate of expenditures required for the management and
  817  provision of a specified set of medical services or long-term
  818  care services needed by members enrolled in a prepaid health
  819  plan.
  820         (6)(5) “Change of ownership” has the same meaning as in s.
  821  408.803 and includes means:
  822         (a) An event in which the provider ownership changes to a
  823  different individual entity as evidenced by a change in federal
  824  employer identification number or taxpayer identification
  825  number;
  826         (b) An event in which 51 percent or more of the ownership,
  827  shares, membership, or controlling interest of a provider is in
  828  any manner transferred or otherwise assigned. This paragraph
  829  does not apply to a licensee that is publicly traded on a
  830  recognized stock exchange; or
  831         (c) When the provider is licensed or registered by the
  832  agency, an event considered a change of ownership under part II
  833  of chapter 408 for licensure as defined in s. 408.803.
  834  
  835  A change solely in the management company or board of directors
  836  is not a change of ownership.
  837         (7)(6) “Claim” means any communication, whether written or
  838  electronic (electronic impulse or magnetic), which is used by
  839  any person to apply for payment from the Medicaid program, or
  840  its fiscal agent, or a qualified plan under part IV of this
  841  chapter for each item or service purported by any person to have
  842  been provided by a person to a any Medicaid recipient.
  843         (8)(7) “Collateral” means:
  844         (a) Any and all causes of action, suits, claims,
  845  counterclaims, and demands that accrue to a the recipient or to
  846  a the recipient’s legal representative, related to any covered
  847  injury, illness, or necessary medical care, goods, or services
  848  that resulted in necessitated that Medicaid providing provide
  849  medical assistance.
  850         (b) All judgments, settlements, and settlement agreements
  851  rendered or entered into and related to such causes of action,
  852  suits, claims, counterclaims, demands, or judgments.
  853         (c) Proceeds, as defined in this section.
  854         (9)(8) “Convicted” or “conviction” means a finding of
  855  guilt, with or without an adjudication of guilt, in any federal
  856  or state trial court of record relating to charges brought by
  857  indictment or information, as a result of a jury verdict,
  858  nonjury trial, or entry of a plea of guilty or nolo contendere,
  859  regardless of whether an appeal from judgment is pending.
  860         (10)(9) “Covered injury or illness” means any sickness,
  861  injury, disease, disability, deformity, abnormality disease,
  862  necessary medical care, pregnancy, or death for which a third
  863  party is, may be, could be, should be, or has been liable, and
  864  for which Medicaid is, or may be, obligated to provide, or has
  865  provided, medical assistance.
  866         (11)(10) “Emergency medical condition” has the same meaning
  867  as in s. 395.002. means:
  868         (a) A medical condition manifesting itself by acute
  869  symptoms of sufficient severity, which may include severe pain
  870  or other acute symptoms, such that the absence of immediate
  871  medical attention could reasonably be expected to result in any
  872  of the following:
  873         1. Serious jeopardy to the health of a patient, including a
  874  pregnant woman or a fetus.
  875         2. Serious impairment to bodily functions.
  876         3. Serious dysfunction of any bodily organ or part.
  877         (b) With respect to a pregnant woman:
  878         1. That there is inadequate time to effect safe transfer to
  879  another hospital prior to delivery.
  880         2. That a transfer may pose a threat to the health and
  881  safety of the patient or fetus.
  882         3. That there is evidence of the onset and persistence of
  883  uterine contractions or rupture of the membranes.
  884         (12)(11) “Emergency services and care” has the same meaning
  885  as in s. 395.002 means medical screening, examination, and
  886  evaluation by a physician, or, to the extent permitted by
  887  applicable laws, by other appropriate personnel under the
  888  supervision of a physician, to determine whether an emergency
  889  medical condition exists and, if it does, the care, treatment,
  890  or surgery for a covered service by a physician which is
  891  necessary to relieve or eliminate the emergency medical
  892  condition, within the service capability of a hospital.
  893         (13)(12) “Legal representative” means a guardian,
  894  conservator, survivor, or personal representative of a recipient
  895  or applicant, or of the property or estate of a recipient or
  896  applicant.
  897         (14)(13) “Managed care plan” means a health insurer
  898  authorized under chapter 624, an exclusive provider organization
  899  authorized under chapter 627, a health maintenance organization
  900  authorized under chapter 641, a provider service network
  901  authorized under s. 409.912(4)(d), or an accountable care
  902  organization authorized under federal law health maintenance
  903  organization authorized pursuant to chapter 641 or a prepaid
  904  health plan authorized pursuant to s. 409.912.
  905         (15)(14) “Medicaid” or Medicaid program means the medical
  906  assistance program authorized by Title XIX of the Social
  907  Security Act, 42 U.S.C. s. 1396 et seq., and regulations
  908  thereunder, as administered in this state by the agency.
  909         (15) “Medicaid agency” or “agency” means the single state
  910  agency that administers or supervises the administration of the
  911  state Medicaid plan under federal law.
  912         (16) “Medicaid program” means the program authorized under
  913  Title XIX of the federal Social Security Act which provides for
  914  payments for medical items or services, or both, on behalf of
  915  any person who is determined by the Department of Children and
  916  Family Services, or, for Supplemental Security Income, by the
  917  Social Security Administration, to be eligible on the date of
  918  service for Medicaid assistance.
  919         (16)(17) “Medicaid provider” or “provider” means a person
  920  or entity that has a Medicaid provider agreement in effect with
  921  the agency and is in good standing with the agency. The term
  922  also includes a person or entity that provides medical services
  923  to a Medicaid recipient under the Medicaid managed care program
  924  in part IV of this chapter.
  925         (17)(18) “Medicaid provider agreement” or “provider
  926  agreement” means a contract between the agency and a provider
  927  for the provision of services or goods, or both, to Medicaid
  928  recipients pursuant to Medicaid.
  929         (18)(19) “Medicaid recipient” or “recipient” means an
  930  individual whom the Department of Children and Family Services,
  931  or, for Supplemental Security Income, by the Social Security
  932  Administration, determines is eligible, pursuant to federal and
  933  state law, to receive medical assistance and related services
  934  for which the agency may make payments under the Medicaid
  935  program. For the purposes of determining third-party liability,
  936  the term includes an individual formerly determined to be
  937  eligible for Medicaid, an individual who has received medical
  938  assistance under the Medicaid program, or an individual on whose
  939  behalf Medicaid has become obligated.
  940         (19)(20) “Medicaid-related records” means records that
  941  relate to the provider’s business or profession and to a
  942  Medicaid recipient. The term includes Medicaid-related records
  943  include records related to non-Medicaid customers, clients, or
  944  patients but only to the extent that the documentation is shown
  945  by the agency to be necessary for determining to determine a
  946  provider’s entitlement to payments under the Medicaid program.
  947         (20)(21) “Medical assistance” means any provision of,
  948  payment for, or liability for medical services or care by
  949  Medicaid to, or on behalf of, a Medicaid any recipient.
  950         (21)(22) “Medical services” or “medical care” means medical
  951  or medically related institutional or noninstitutional care,
  952  goods, or services covered by the Medicaid program. The term
  953  includes any services authorized and funded in the General
  954  Appropriations Act.
  955         (22)(23) “MediPass” means a primary care case management
  956  program operated by the agency.
  957         (23)(24) “Minority physician network” means a network of
  958  primary care physicians with experience in managing Medicaid or
  959  Medicare recipients which that is predominantly owned by
  960  minorities, as defined in s. 288.703, and which may have a
  961  collaborative partnership with a public college or university
  962  and a tax-exempt charitable corporation.
  963         (24)(25) “Payment,” as it relates to third-party benefits,
  964  means performance of a duty, promise, or obligation, or
  965  discharge of a debt or liability, by the delivery, provision, or
  966  transfer of third-party benefits for medical services. To “pay”
  967  means to do any of the acts set forth in this subsection.
  968         (25)(26) “Proceeds” means whatever is received upon the
  969  sale, exchange, collection, or other disposition of the
  970  collateral or proceeds thereon and includes insurance payable by
  971  reason of loss or damage to the collateral or proceeds. Money,
  972  checks, deposit accounts, and the like are “cash proceeds.” All
  973  other proceeds are “noncash proceeds.”
  974         (26)(27) “Third party” means an individual, entity, or
  975  program, excluding Medicaid, that is, may be, could be, should
  976  be, or has been liable for all or part of the cost of medical
  977  services related to any medical assistance covered by Medicaid.
  978  A third party includes a third-party administrator or a pharmacy
  979  benefits manager.
  980         (27)(28) “Third-party benefit” means any benefit that is or
  981  may be available at any time through contract, court award,
  982  judgment, settlement, agreement, or any arrangement between a
  983  third party and any person or entity, including, without
  984  limitation, a Medicaid recipient, a provider, another third
  985  party, an insurer, or the agency, for any Medicaid-covered
  986  injury, illness, goods, or services, including costs of medical
  987  services related thereto, for personal injury or for death of
  988  the recipient, but specifically excluding policies of life
  989  insurance on the recipient, unless available under terms of the
  990  policy to pay medical expenses prior to death. The term
  991  includes, without limitation, collateral, as defined in this
  992  section, health insurance, any benefit under a health
  993  maintenance organization, a preferred provider arrangement, a
  994  prepaid health clinic, liability insurance, uninsured motorist
  995  insurance or personal injury protection coverage, medical
  996  benefits under workers’ compensation, and any obligation under
  997  law or equity to provide medical support.
  998         Section 18. Section 409.902, Florida Statutes, is amended
  999  to read:
 1000         409.902 Designated single state agency; eligibility
 1001  determinations; rules payment requirements; program title;
 1002  release of medical records.—
 1003         (1) The agency for Health Care Administration is designated
 1004  as the single state agency authorized to administer the Medicaid
 1005  state plan and to make payments for medical assistance and
 1006  related services under Title XIX of the Social Security Act.
 1007  These payments shall be made, subject to any limitations or
 1008  directions provided for in the General Appropriations Act, only
 1009  for services included in the Medicaid program, shall be made
 1010  only on behalf of eligible individuals, and shall be made only
 1011  to qualified providers in accordance with federal requirements
 1012  under for Title XIX of the Social Security Act and the
 1013  provisions of state law.
 1014         (a) The agency must notify the Legislature before seeking
 1015  an amendment to the state plan for purposes of implementing
 1016  provisions authorized by the Deficit Reduction Act of 2005.
 1017         (b) The agency shall adopt any rules necessary to carry out
 1018  its statutory duties under this subsection and any other
 1019  statutory provisions related to its responsibility for the
 1020  Medicaid program and state compliance with federal Medicaid
 1021  requirements, including the Medicaid managed care program. This
 1022  program of medical assistance is designated the “Medicaid
 1023  program.”
 1024         (2) The Department of Children and Family Services is
 1025  responsible for determining Medicaid eligibility determinations,
 1026  including, but not limited to, policy, rules, and the agreement
 1027  with the Social Security Administration for Medicaid eligibility
 1028  determinations for Supplemental Security Income recipients, as
 1029  well as the actual determination of eligibility. As a condition
 1030  of Medicaid eligibility, subject to federal approval, the agency
 1031  for Health Care Administration and the Department of Children
 1032  and Family Services shall ensure that each recipient of Medicaid
 1033  consents to the release of her or his medical records to the
 1034  agency for Health Care Administration and the Medicaid Fraud
 1035  Control Unit of the Department of Legal Affairs.
 1036         (a) Eligibility is restricted to United States citizens and
 1037  to lawfully admitted noncitizens who meet the criteria provided
 1038  in s. 414.095(3).
 1039         1. Citizenship or immigration status must be verified. For
 1040  noncitizens, this includes verification of the validity of
 1041  documents with the United States Citizenship and Immigration
 1042  Services using the federal SAVE verification process.
 1043         2. State funds may not be used to provide medical services
 1044  to individuals who do not meet the requirements of this
 1045  paragraph unless the services are necessary to treat an
 1046  emergency medical condition or are for pregnant women. Such
 1047  services are authorized only to the extent provided under
 1048  federal law and in accordance with federal regulations as
 1049  provided in 42 C.F.R. s. 440.255.
 1050         (b) When adopting rules relating to eligibility for
 1051  institutional care services, hospice services, and home and
 1052  community-based waiver programs, and regardless of whether a
 1053  penalty will be applied due to the unlawful transfer of assets,
 1054  the payment of fair compensation by an applicant for a personal
 1055  care services contract entered into on or after October 1, 2011,
 1056  shall be evaluated using the following criteria:
 1057         1. The contracted services do not duplicate services
 1058  available through other sources or providers, such as Medicaid,
 1059  Medicare, private insurance, or another legally obligated third
 1060  party;
 1061         2. The contracted services directly benefit the individual
 1062  and are not services normally provided out of love and
 1063  consideration for the individual;
 1064         3. The actual cost to deliver services is computed in a
 1065  manner that clearly reflects the actual number of hours to be
 1066  expended, and the contract clearly identifies each specific
 1067  service and the average number of hours of each service to be
 1068  delivered each month;
 1069         4. The hourly rate for each contracted service is equal to
 1070  or less than the amount normally charged by a professional who
 1071  traditionally provides the same or similar services;
 1072         5. The contracted services are provided on a prospective
 1073  basis only and not for services provided in the past; and
 1074         6. The contract provides fair compensation to the
 1075  individual in his or her lifetime as set forth in life
 1076  expectancy tables adopted in rule 65A-1.716, Florida
 1077  Administrative Code.
 1078         (c) The department shall adopt any rules necessary to carry
 1079  out its statutory duties under this subsection for receiving and
 1080  processing Medicaid applications and determining Medicaid
 1081  eligibility, and any other statutory provisions related to
 1082  responsibility for the determination of Medicaid eligibility.
 1083         Section 19. Section 409.9021, Florida Statutes, is amended
 1084  to read:
 1085         409.9021 Conditions for Medicaid Forfeiture of eligibility
 1086  agreement.—As a condition of Medicaid eligibility, subject to
 1087  federal regulation and approval:,
 1088         (1) A Medicaid applicant must consent shall agree in
 1089  writing to:
 1090         (a) Have her or his medical records released to the agency
 1091  and the Medicaid Fraud Control Unit of the Department of Legal
 1092  Affairs.
 1093         (b) Forfeit all entitlements to any goods or services
 1094  provided through the Medicaid program for the next 10 years if
 1095  he or she has been found to have committed Medicaid fraud,
 1096  through judicial or administrative determination, two times in a
 1097  period of 5 years. This provision applies only to the Medicaid
 1098  recipient found to have committed or participated in Medicaid
 1099  the fraud and does not apply to any family member of the
 1100  recipient who was not involved in the fraud.
 1101         (2) A Medicaid applicant must pay a $10 monthly premium
 1102  that covers all Medicaid-eligible recipients in the applicant’s
 1103  family. However, an individual who is eligible for the
 1104  Supplemental Security Income related Medicaid and is receiving
 1105  institutional care payments is exempt from this requirement. The
 1106  agency shall seek a federal waiver to authorize the imposition
 1107  and collection of this premium effective December 31, 2011. Upon
 1108  approval, the agency shall establish by rule procedures for
 1109  collecting premiums from recipients, advance notice of
 1110  cancellation, and waiting periods for reinstatement of coverage
 1111  upon voluntary cancellation for nonpayment of premiums.
 1112         (3) A Medicaid applicant must participate, in good faith,
 1113  in:
 1114         (a) A medically approved smoking cessation program if the
 1115  applicant smokes.
 1116         (b) A medically directed weight loss program if the
 1117  applicant is or becomes morbidly obese.
 1118         (c) A medically approved alcohol or substance abuse
 1119  recovery program if the applicant is or becomes diagnosed as a
 1120  substance abuser.
 1121  
 1122  The agency shall seek a federal waiver to authorize the
 1123  implementation of this subsection in order to assist the
 1124  recipient in mitigating lifestyle choices and avoiding behaviors
 1125  associated with the use of high-cost medical services.
 1126         (4)A person who is eligible for Medicaid services and who
 1127  has access to health care coverage through an employer-sponsored
 1128  health plan may not receive Medicaid services reimbursed under
 1129  s. 409.908, s. 409.912,or s. 409.986, but may use Medicaid
 1130  financial assistance to pay the cost of premiums for the
 1131  employer-sponsored health plan for the eligible person and his
 1132  or her Medicaid-eligible family members.
 1133         (5) A Medicaid recipient who has access to other insurance
 1134  or coverage created pursuant to state or federal law may opt out
 1135  of the Medicaid services provided under s. 409.908, s. 409.912,
 1136  or s. 409.986 and use Medicaid financial assistance to pay the
 1137  cost of premiums for the recipient and the recipient’s Medicaid
 1138  eligible family members.
 1139         (6) Subsections (4) and (5) shall be administered by the
 1140  agency in accordance with s. 409.964(1)(j). The maximum amount
 1141  available for the Medicaid financial assistance shall be
 1142  calculated based on the Medicaid capitated rate as if the
 1143  Medicaid recipient and the recipient’s eligible family members
 1144  participated in a qualified plan for Medicaid managed care under
 1145  part IV of this chapter.
 1146         Section 20. Section 409.9022, Florida Statutes, is created
 1147  to read:
 1148         409.9022 Limitations on Medicaid expenditures.—
 1149         (1) Except as specifically authorized in this section, a
 1150  state agency may not obligate or expend funds for the Medicaid
 1151  program in excess of the amount appropriated in the General
 1152  Appropriations Act.
 1153         (2) If, at any time during the fiscal year, a state agency
 1154  determines that Medicaid expenditures may exceed the amount
 1155  appropriated during the fiscal year, the state agency shall
 1156  notify the Social Services Estimating Conference, which shall
 1157  meet to estimate Medicaid expenditures for the remainder of the
 1158  fiscal year. If, pursuant to this paragraph or for any other
 1159  purpose, the conference determines that Medicaid expenditures
 1160  will exceed appropriations for the fiscal year, the state agency
 1161  shall develop and submit a plan for revising Medicaid
 1162  expenditures in order to remain within the annual appropriation.
 1163  The plan must include cost-mitigating strategies to negate the
 1164  projected deficit for the remainder of the fiscal year and shall
 1165  be submitted in the form of a budget amendment to the
 1166  Legislative Budget Commission. The conference shall also
 1167  estimate the amount of savings which will result from such cost
 1168  mitigating strategies proposed by the state agency as well as
 1169  any other strategies the conference may consider and recommend.
 1170         (3) In preparing the budget amendment to revise Medicaid
 1171  expenditures in order to remain within appropriations, a state
 1172  agency shall include the following revisions to the Medicaid
 1173  state plan, in the priority order listed below:
 1174         (a) Reduction in administrative costs.
 1175         (b) Elimination of optional benefits.
 1176         (c) Elimination of optional eligibility groups.
 1177         (d) Reduction to institutional and provider reimbursement
 1178  rates.
 1179         (e) Reduction in the amount, duration, and scope of
 1180  mandatory benefits.
 1181  
 1182  The state agency may not implement any of these cost-containment
 1183  measures until the amendment is approved by the Legislative
 1184  Budget Commission.
 1185         (4) In order to remedy a projected expenditure in excess of
 1186  the amount appropriated in a specific appropriation within the
 1187  Medicaid budget, a state agency may, consistent with chapter
 1188  216:
 1189         (a) Submit a budget amendment to transfer budget authority
 1190  between appropriation categories;
 1191         (b) Submit a budget amendment to increase federal trust
 1192  authority or grants and donations trust authority if additional
 1193  federal or local funds are available; or
 1194         (c) Submit any other budget amendment consistent with
 1195  chapter 216.
 1196         (5) The agency shall amend the Medicaid state plan to
 1197  incorporate the provisions of this section.
 1198         (6) Chapter 216 does not permit the transfer of funds from
 1199  any other program into the Medicaid program or the transfer of
 1200  funds out of the Medicaid program into any other program.
 1201         Section 21. Section 409.903, Florida Statutes, is amended
 1202  to read:
 1203         409.903 Mandatory payments for eligible persons.—The agency
 1204  shall make payments for medical assistance and related services
 1205  on behalf of the following categories of persons who the
 1206  Department of Children and Family Services, or the Social
 1207  Security Administration by contract with the department of
 1208  Children and Family Services, determines to be eligible for
 1209  Medicaid, subject to the income, assets, and categorical
 1210  eligibility tests set forth in federal and state law. Payment on
 1211  behalf of these recipients Medicaid eligible persons is subject
 1212  to the availability of moneys and any limitations established by
 1213  the General Appropriations Act, or chapter 216, or s. 409.9022.
 1214         (1) Low-income families with children if are eligible for
 1215  Medicaid provided they meet the following requirements:
 1216         (a) The family includes a dependent child who is living
 1217  with a caretaker relative.
 1218         (b) The family’s income does not exceed the gross income
 1219  test limit.
 1220         (c) The family’s countable income and resources do not
 1221  exceed the applicable Aid to Families with Dependent Children
 1222  (AFDC) income and resource standards under the AFDC state plan
 1223  in effect on in July 1996, except as amended in the Medicaid
 1224  state plan to conform as closely as possible to the requirements
 1225  of the welfare transition program, to the extent permitted by
 1226  federal law.
 1227         (2) A person who receives payments from, who is determined
 1228  eligible for, or who was eligible for but lost cash benefits
 1229  from the federal program known as the Supplemental Security
 1230  Income program (SSI). This category includes a low-income person
 1231  age 65 or over and a low-income person under age 65 considered
 1232  to be permanently and totally disabled.
 1233         (3) A child under age 21 living in a low-income, two-parent
 1234  family, and a child under age 7 living with a nonrelative, if
 1235  the income and assets of the family or child, as applicable, do
 1236  not exceed the resource limits under the Temporary Cash
 1237  Assistance Program.
 1238         (4) A child who is eligible under Title IV-E of the Social
 1239  Security Act for subsidized board payments, foster care, or
 1240  adoption subsidies, and a child for whom the state has assumed
 1241  temporary or permanent responsibility and who does not qualify
 1242  for Title IV-E assistance but is in foster care, shelter or
 1243  emergency shelter care, or subsidized adoption. This category
 1244  includes a young adult who is eligible to receive services under
 1245  s. 409.1451(5), until the young adult reaches 21 years of age,
 1246  without regard to any income, resource, or categorical
 1247  eligibility test that is otherwise required. This category also
 1248  includes a person who as a child was eligible under Title IV-E
 1249  of the Social Security Act for foster care or the state-provided
 1250  foster care and who is a participant in the Road-to-Independence
 1251  Program.
 1252         (5) A pregnant woman for the duration of her pregnancy and
 1253  for the postpartum period as defined in federal law and rule, or
 1254  a child under age 1, if either is living in a family that has an
 1255  income which is at or below 150 percent of the most current
 1256  federal poverty level, or, effective January 1, 1992, that has
 1257  an income which is at or below 185 percent of the most current
 1258  federal poverty level. Such a person is not subject to an assets
 1259  test. Further, A pregnant woman who applies for eligibility for
 1260  the Medicaid program through a qualified Medicaid provider must
 1261  be offered the opportunity, subject to federal rules, to be made
 1262  presumptively eligible for the Medicaid program.
 1263         (6) A child born after September 30, 1983, living in a
 1264  family that has an income which is at or below 100 percent of
 1265  the current federal poverty level, who has attained the age of
 1266  6, but has not attained the age of 19. In determining the
 1267  eligibility of such a child, an assets test is not required. A
 1268  child who is eligible for Medicaid under this subsection must be
 1269  offered the opportunity, subject to federal rules, to be made
 1270  presumptively eligible. A child who has been deemed
 1271  presumptively eligible may for Medicaid shall not be enrolled in
 1272  a managed care plan until the child’s full eligibility
 1273  determination for Medicaid has been determined completed.
 1274         (7) A child living in a family that has an income that
 1275  which is at or below 133 percent of the current federal poverty
 1276  level, who has attained the age of 1, but has not attained the
 1277  age of 6. In determining the eligibility of such a child, an
 1278  assets test is not required. A child who is eligible for
 1279  Medicaid under this subsection must be offered the opportunity,
 1280  subject to federal rules, to be made presumptively eligible. A
 1281  child who has been deemed presumptively eligible may for
 1282  Medicaid shall not be enrolled in a managed care plan until the
 1283  child’s full eligibility determination for Medicaid has been
 1284  determined completed.
 1285         (8) A person who is age 65 or over or is determined by the
 1286  agency to be disabled, whose income is at or below 100 percent
 1287  of the most current federal poverty level and whose assets do
 1288  not exceed limitations established by the agency. However, the
 1289  agency may only pay for premiums, coinsurance, and deductibles,
 1290  as required by federal law, unless additional coverage is
 1291  provided for any or all members of this group under by s.
 1292  409.904(1).
 1293         Section 22. Section 409.904, Florida Statutes, is amended
 1294  to read:
 1295         409.904 Optional payments for eligible persons.—The agency
 1296  may make payments for medical assistance and related services on
 1297  behalf of the following categories of persons who are determined
 1298  to be eligible for Medicaid, subject to the income, assets, and
 1299  categorical eligibility tests set forth in federal and state
 1300  law. Payment on behalf of these Medicaid eligible persons is
 1301  subject to the availability of moneys and any limitations
 1302  established by the General Appropriations Act, or chapter 216,
 1303  or s. 409.9022.
 1304         (1) Effective January 1, 2006, and Subject to federal
 1305  waiver approval, a person who is age 65 or older or is
 1306  determined to be disabled, whose income is at or below 88
 1307  percent of the federal poverty level, whose assets do not exceed
 1308  established limitations, and who is not eligible for Medicare
 1309  or, if eligible for Medicare, is also eligible for and receiving
 1310  Medicaid-covered institutional care services, hospice services,
 1311  or home and community-based services. The agency shall seek
 1312  federal authorization through a waiver to provide this coverage.
 1313  This subsection expires June 30, 2011.
 1314         (2) The following persons who are eligible for the Medicaid
 1315  nonpoverty medical subsidy, which includes the same services as
 1316  those provided to other Medicaid recipients, with the exception
 1317  of services in skilled nursing facilities and intermediate care
 1318  facilities for the developmentally disabled:
 1319         (a) A family, a pregnant woman, a child under age 21, a
 1320  person age 65 or over, or a blind or disabled person, who would
 1321  be eligible under any group listed in s. 409.903(1), (2), or
 1322  (3), except that the income or assets of such family or person
 1323  exceed established limitations. For a family or person in one of
 1324  these coverage groups, medical expenses are deductible from
 1325  income in accordance with federal requirements in order to make
 1326  a determination of eligibility. A family or person eligible
 1327  under the coverage known as the “medically needy,” is eligible
 1328  to receive the same services as other Medicaid recipients, with
 1329  the exception of services in skilled nursing facilities and
 1330  intermediate care facilities for the developmentally disabled.
 1331  This paragraph expires June 30, 2011.
 1332         (b) Effective June 30 July 1, 2011, a pregnant woman or a
 1333  child younger than 21 years of age who would be eligible under
 1334  any group listed in s. 409.903, except that the income or assets
 1335  of such group exceed established limitations. For a person in
 1336  one of these coverage groups, medical expenses are deductible
 1337  from income in accordance with federal requirements in order to
 1338  make a determination of eligibility. A person eligible under the
 1339  coverage known as the “medically needy” is eligible to receive
 1340  the same services as other Medicaid recipients, with the
 1341  exception of services in skilled nursing facilities and
 1342  intermediate care facilities for the developmentally disabled.
 1343         (c)A family, a person age 65 or older, or a blind or
 1344  disabled person, who would be eligible under any group listed in
 1345  s. 409.903(1), (2), or (3), except that the income or assets of
 1346  such family or person exceed established limitations. For a
 1347  family or person in one of these coverage groups, medical
 1348  expenses are deductible from income in accordance with federal
 1349  requirements in order to make a determination of eligibility. A
 1350  family, a person age 65 or older, or a blind or disabled person,
 1351  covered under the Medicaid nonpoverty medical subsidy, is
 1352  eligible to receive physician services only.
 1353         (3) A person who is in need of the services of a licensed
 1354  nursing facility, a licensed intermediate care facility for the
 1355  developmentally disabled, or a state mental hospital, whose
 1356  income does not exceed 300 percent of the SSI income standard,
 1357  and who meets the assets standards established under federal and
 1358  state law. In determining the person’s responsibility for the
 1359  cost of care, the following amounts must be deducted from the
 1360  person’s income:
 1361         (a) The monthly personal allowance for residents as set
 1362  based on appropriations.
 1363         (b) The reasonable costs of medically necessary services
 1364  and supplies that are not reimbursable by the Medicaid program.
 1365         (c) The cost of premiums, copayments, coinsurance, and
 1366  deductibles for supplemental health insurance.
 1367         (4) A low-income person who meets all other requirements
 1368  for Medicaid eligibility except citizenship and who is in need
 1369  of emergency medical services. The eligibility of such a
 1370  recipient is limited to the period of the emergency, in
 1371  accordance with federal regulations.
 1372         (5) Subject to specific federal authorization, a woman
 1373  living in a family that has an income that is at or below 185
 1374  percent of the most current federal poverty level. Coverage is
 1375  limited to is eligible for family planning services as specified
 1376  in s. 409.905(3) for a period of up to 24 months following a
 1377  loss of Medicaid benefits.
 1378         (6) A child who has not attained the age of 19 who has been
 1379  determined eligible for the Medicaid program is deemed to be
 1380  eligible for a total of 6 months, regardless of changes in
 1381  circumstances other than attainment of the maximum age.
 1382  Effective January 1, 1999, A child who has not attained the age
 1383  of 5 and who has been determined eligible for the Medicaid
 1384  program is deemed to be eligible for a total of 12 months
 1385  regardless of changes in circumstances other than attainment of
 1386  the maximum age.
 1387         (7) A child under 1 year of age who lives in a family that
 1388  has an income above 185 percent of the most recently published
 1389  federal poverty level, but which is at or below 200 percent of
 1390  such poverty level. In determining the eligibility of such
 1391  child, an assets test is not required. A child who is eligible
 1392  for Medicaid under this subsection must be offered the
 1393  opportunity, subject to federal rules, to be made presumptively
 1394  eligible.
 1395         (8) An eligible person A Medicaid-eligible individual for
 1396  the individual’s health insurance premiums, if the agency
 1397  determines that such payments are cost-effective.
 1398         (9) Eligible women with incomes at or below 200 percent of
 1399  the federal poverty level and under age 65, for cancer treatment
 1400  pursuant to the federal Breast and Cervical Cancer Prevention
 1401  and Treatment Act of 2000, screened through the Mary Brogan
 1402  Breast and Cervical Cancer Early Detection Program established
 1403  under s. 381.93.
 1404         Section 23. Section 409.905, Florida Statutes, is amended
 1405  to read:
 1406         409.905 Mandatory Medicaid services.—The agency shall may
 1407  make payments for the following services, which are required of
 1408  the state by Title XIX of the Social Security Act, furnished by
 1409  Medicaid providers to recipients who are determined to be
 1410  eligible on the dates on which the services were provided. Any
 1411  service under this section shall be provided only when medically
 1412  necessary and in accordance with state and federal law.
 1413  Mandatory services rendered by providers in mobile units to
 1414  Medicaid recipients may be restricted by the agency. This
 1415  section does not Nothing in this section shall be construed to
 1416  prevent or limit the agency from adjusting fees, reimbursement
 1417  rates, lengths of stay, number of visits, number of services, or
 1418  any other adjustments necessary to comply with the availability
 1419  of moneys and any limitations or directions provided for in the
 1420  General Appropriations Act, or chapter 216, or s. 409.9022.
 1421         (1) ADVANCED REGISTERED NURSE PRACTITIONER SERVICES.—The
 1422  agency shall pay for services provided to a recipient by a
 1423  licensed advanced registered nurse practitioner who has a valid
 1424  collaboration agreement with a licensed physician on file with
 1425  the Department of Health or who provides anesthesia services in
 1426  accordance with established protocol required by state law and
 1427  approved by the medical staff of the facility in which the
 1428  anesthetic service is performed. Reimbursement for such services
 1429  must be provided in an amount that equals at least not less than
 1430  80 percent of the reimbursement to a physician who provides the
 1431  same services, unless otherwise provided for in the General
 1432  Appropriations Act.
 1433         (2) EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT
 1434  SERVICES.—The agency shall pay for early and periodic screening
 1435  and diagnosis of a recipient under age 21 to ascertain physical
 1436  and mental problems and conditions and provide treatment to
 1437  correct or ameliorate these problems and conditions. These
 1438  services include all services determined by the agency to be
 1439  medically necessary for the treatment, correction, or
 1440  amelioration of these problems and conditions, including
 1441  personal care, private duty nursing, durable medical equipment,
 1442  physical therapy, occupational therapy, speech therapy,
 1443  respiratory therapy, and immunizations.
 1444         (3) FAMILY PLANNING SERVICES.—The agency shall pay for
 1445  services necessary to enable a recipient voluntarily to plan
 1446  family size or to space children. These services include
 1447  information; education; counseling regarding the availability,
 1448  benefits, and risks of each method of pregnancy prevention;
 1449  drugs and supplies; and necessary medical care and followup.
 1450  Each recipient participating in the family planning portion of
 1451  the Medicaid program must be provided the choice of freedom to
 1452  choose any alternative method of family planning, as required by
 1453  federal law.
 1454         (4) HOME HEALTH CARE SERVICES.—The agency shall pay for
 1455  nursing and home health aide services, supplies, appliances, and
 1456  durable medical equipment, necessary to assist a recipient
 1457  living at home. An entity that provides such services must
 1458  pursuant to this subsection shall be licensed under part III of
 1459  chapter 400. These services, equipment, and supplies, or
 1460  reimbursement therefor, may be limited as provided in the
 1461  General Appropriations Act and do not include services,
 1462  equipment, or supplies provided to a person residing in a
 1463  hospital or nursing facility.
 1464         (a) In providing home health care services, The agency
 1465  shall may require prior authorization of home health services
 1466  care based on diagnosis, utilization rates, and or billing
 1467  rates. The agency shall require prior authorization for visits
 1468  for home health services that are not associated with a skilled
 1469  nursing visit when the home health agency billing rates exceed
 1470  the state average by 50 percent or more. The home health agency
 1471  must submit the recipient’s plan of care and documentation that
 1472  supports the recipient’s diagnosis to the agency when requesting
 1473  prior authorization.
 1474         (b) The agency shall implement a comprehensive utilization
 1475  management program that requires prior authorization of all
 1476  private duty nursing services, an individualized treatment plan
 1477  that includes information about medication and treatment orders,
 1478  treatment goals, methods of care to be used, and plans for care
 1479  coordination by nurses and other health professionals. The
 1480  utilization management program must shall also include a process
 1481  for periodically reviewing the ongoing use of private duty
 1482  nursing services. The assessment of need shall be based on a
 1483  child’s condition;, family support and care supplements;, a
 1484  family’s ability to provide care;, and a family’s and child’s
 1485  schedule regarding work, school, sleep, and care for other
 1486  family dependents; and a determination of the medical necessity
 1487  for private duty nursing instead of other more cost-effective
 1488  in-home services. When implemented, the private duty nursing
 1489  utilization management program shall replace the current
 1490  authorization program used by the agency for Health Care
 1491  Administration and the Children’s Medical Services program of
 1492  the Department of Health. The agency may competitively bid on a
 1493  contract to select a qualified organization to provide
 1494  utilization management of private duty nursing services. The
 1495  agency may is authorized to seek federal waivers to implement
 1496  this initiative.
 1497         (c) The agency may not pay for home health services unless
 1498  the services are medically necessary and:
 1499         1. The services are ordered by a physician.
 1500         2. The written prescription for the services is signed and
 1501  dated by the recipient’s physician before the development of a
 1502  plan of care and before any request requiring prior
 1503  authorization.
 1504         3. The physician ordering the services is not employed,
 1505  under contract with, or otherwise affiliated with the home
 1506  health agency rendering the services. However, this subparagraph
 1507  does not apply to a home health agency affiliated with a
 1508  retirement community, of which the parent corporation or a
 1509  related legal entity owns a rural health clinic certified under
 1510  42 C.F.R. part 491, subpart A, ss. 1-11, a nursing home licensed
 1511  under part II of chapter 400, or an apartment or single-family
 1512  home for independent living. For purposes of this subparagraph,
 1513  the agency may, on a case-by-case basis, provide an exception
 1514  for medically fragile children who are younger than 21 years of
 1515  age.
 1516         4. The physician ordering the services has examined the
 1517  recipient within the 30 days preceding the initial request for
 1518  the services and biannually thereafter.
 1519         5. The written prescription for the services includes the
 1520  recipient’s acute or chronic medical condition or diagnosis, the
 1521  home health service required, and, for skilled nursing services,
 1522  the frequency and duration of the services.
 1523         6. The national provider identifier, Medicaid
 1524  identification number, or medical practitioner license number of
 1525  the physician ordering the services is listed on the written
 1526  prescription for the services, the claim for home health
 1527  reimbursement, and the prior authorization request.
 1528         (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
 1529  all covered services provided for the medical care and treatment
 1530  of a recipient who is admitted as an inpatient by a licensed
 1531  physician or dentist to a hospital licensed under part I of
 1532  chapter 395. However, the agency shall limit the payment for
 1533  inpatient hospital services for a Medicaid recipient 21 years of
 1534  age or older to 45 days or the number of days necessary to
 1535  comply with the General Appropriations Act.
 1536         (a) The agency may is authorized to implement reimbursement
 1537  and utilization management reforms in order to comply with any
 1538  limitations or directions in the General Appropriations Act,
 1539  which may include, but are not limited to: prior authorization
 1540  for inpatient psychiatric days; prior authorization for
 1541  nonemergency hospital inpatient admissions for individuals 21
 1542  years of age and older; authorization of emergency and urgent
 1543  care admissions within 24 hours after admission; enhanced
 1544  utilization and concurrent review programs for highly utilized
 1545  services; reduction or elimination of covered days of service;
 1546  adjusting reimbursement ceilings for variable costs; adjusting
 1547  reimbursement ceilings for fixed and property costs; and
 1548  implementing target rates of increase. The agency may limit
 1549  prior authorization for hospital inpatient services to selected
 1550  diagnosis-related groups, based on an analysis of the cost and
 1551  potential for unnecessary hospitalizations represented by
 1552  certain diagnoses. Admissions for normal delivery and newborns
 1553  are exempt from requirements for prior authorization. In
 1554  implementing the provisions of this section related to prior
 1555  authorization, the agency must shall ensure that the process for
 1556  authorization is accessible 24 hours per day, 7 days per week
 1557  and that authorization is automatically granted if when not
 1558  denied within 4 hours after the request. Authorization
 1559  procedures must include steps for reviewing review of denials.
 1560  Upon implementing the prior authorization program for hospital
 1561  inpatient services, the agency shall discontinue its hospital
 1562  retrospective review program.
 1563         (b) A licensed hospital maintained primarily for the care
 1564  and treatment of patients having mental disorders or mental
 1565  diseases may is not eligible to participate in the hospital
 1566  inpatient portion of the Medicaid program except as provided in
 1567  federal law. However, the Department of Children and Family
 1568  Services shall apply for a waiver, within 9 months after June 5,
 1569  1991, designed to provide hospitalization services for mental
 1570  health reasons to children and adults in the most cost-effective
 1571  and lowest cost setting possible. Such waiver shall include a
 1572  request for the opportunity to pay for care in hospitals known
 1573  under federal law as “institutions for mental disease” or
 1574  “IMD’s.” The waiver proposal shall propose no additional
 1575  aggregate cost to the state or Federal Government, and shall be
 1576  conducted in Hillsborough County, Highlands County, Hardee
 1577  County, Manatee County, and Polk County. The waiver proposal may
 1578  incorporate competitive bidding for hospital services,
 1579  comprehensive brokering, prepaid capitated arrangements, or
 1580  other mechanisms deemed by the department to show promise in
 1581  reducing the cost of acute care and increasing the effectiveness
 1582  of preventive care. When developing the waiver proposal, the
 1583  department shall take into account price, quality,
 1584  accessibility, linkages of the hospital to community services
 1585  and family support programs, plans of the hospital to ensure the
 1586  earliest discharge possible, and the comprehensiveness of the
 1587  mental health and other health care services offered by
 1588  participating providers.
 1589         (c) The agency shall adjust a hospital’s current inpatient
 1590  per diem rate to reflect the cost of serving the Medicaid
 1591  population at that institution if:
 1592         1. The hospital experiences an increase in Medicaid
 1593  caseload by more than 25 percent in any year, primarily
 1594  resulting from the closure of a hospital in the same service
 1595  area occurring after July 1, 1995;
 1596         2. The hospital’s Medicaid per diem rate is at least 25
 1597  percent below the Medicaid per patient cost for that year; or
 1598         3. The hospital is located in a county that has six or
 1599  fewer general acute care hospitals, began offering obstetrical
 1600  services on or after September 1999, and has submitted a request
 1601  in writing to the agency for a rate adjustment after July 1,
 1602  2000, but before September 30, 2000, in which case such
 1603  hospital’s Medicaid inpatient per diem rate shall be adjusted to
 1604  cost, effective July 1, 2002. By October 1 of each year, the
 1605  agency must provide estimated costs for any adjustment in a
 1606  hospital inpatient per diem rate to the Executive Office of the
 1607  Governor, the House of Representatives General Appropriations
 1608  Committee, and the Senate Appropriations Committee. Before the
 1609  agency implements a change in a hospital’s inpatient per diem
 1610  rate pursuant to this paragraph, the Legislature must have
 1611  specifically appropriated sufficient funds in the General
 1612  Appropriations Act to support the increase in cost as estimated
 1613  by the agency.
 1614         (d) The agency shall implement a hospitalist program in
 1615  nonteaching hospitals, select counties, or statewide. The
 1616  program shall require hospitalists to manage Medicaid
 1617  recipients’ hospital admissions and lengths of stay. Individuals
 1618  who are dually eligible for Medicare and Medicaid are exempted
 1619  from this requirement. Medicaid participating physicians and
 1620  other practitioners with hospital admitting privileges shall
 1621  coordinate and review admissions of Medicaid recipients with the
 1622  hospitalist. The agency may competitively bid a contract for
 1623  selection of a single qualified organization to provide
 1624  hospitalist services. The agency may procure hospitalist
 1625  services by individual county or may combine counties in a
 1626  single procurement. The qualified organization shall contract
 1627  with or employ board-eligible physicians in Miami-Dade, Palm
 1628  Beach, Hillsborough, Pasco, and Pinellas Counties. The agency
 1629  may is authorized to seek federal waivers to implement this
 1630  program.
 1631         (e) The agency shall implement a comprehensive utilization
 1632  management program for hospital neonatal intensive care stays in
 1633  certain high-volume participating hospitals, select counties, or
 1634  statewide, and shall replace existing hospital inpatient
 1635  utilization management programs for neonatal intensive care
 1636  admissions. The program shall be designed to manage the lengths
 1637  of stay for children being treated in neonatal intensive care
 1638  units and must seek the earliest medically appropriate discharge
 1639  to the child’s home or other less costly treatment setting. The
 1640  agency may competitively bid a contract for selection of a
 1641  qualified organization to provide neonatal intensive care
 1642  utilization management services. The agency may is authorized to
 1643  seek any federal waivers to implement this initiative.
 1644         (f) The agency may develop and implement a program to
 1645  reduce the number of hospital readmissions among the non
 1646  Medicare population eligible in areas 9, 10, and 11.
 1647         (6) HOSPITAL OUTPATIENT SERVICES.—The agency shall pay for
 1648  preventive, diagnostic, therapeutic, or palliative care and
 1649  other services provided to a recipient in the outpatient portion
 1650  of a hospital licensed under part I of chapter 395, and provided
 1651  under the direction of a licensed physician or licensed dentist,
 1652  except that payment for such care and services is limited to
 1653  $1,500 per state fiscal year per recipient, unless an exception
 1654  has been made by the agency, and with the exception of a
 1655  Medicaid recipient under age 21, in which case the only
 1656  limitation is medical necessity.
 1657         (7) INDEPENDENT LABORATORY SERVICES.—The agency shall pay
 1658  for medically necessary diagnostic laboratory procedures ordered
 1659  by a licensed physician or other licensed health care
 1660  practitioner of the healing arts which are provided for a
 1661  recipient in a laboratory that meets the requirements for
 1662  Medicare participation and is licensed under chapter 483, if
 1663  required.
 1664         (8) NURSING FACILITY SERVICES.—The agency shall pay for 24
 1665  hour-a-day nursing and rehabilitative services for a recipient
 1666  in a nursing facility licensed under part II of chapter 400 or
 1667  in a rural hospital, as defined in s. 395.602, or in a Medicare
 1668  certified skilled nursing facility operated by a general
 1669  hospital, as defined in by s. 395.002(10), which that is
 1670  licensed under part I of chapter 395, and in accordance with
 1671  provisions set forth in s. 409.908(2)(a), which services are
 1672  ordered by and provided under the direction of a licensed
 1673  physician. However, if a nursing facility has been destroyed or
 1674  otherwise made uninhabitable by natural disaster or other
 1675  emergency and another nursing facility is not available, the
 1676  agency must pay for similar services temporarily in a hospital
 1677  licensed under part I of chapter 395 provided federal funding is
 1678  approved and available. The agency shall pay only for bed-hold
 1679  days if the facility has an occupancy rate of 95 percent or
 1680  greater. The agency is authorized to seek any federal waivers to
 1681  implement this policy.
 1682         (9) PHYSICIAN SERVICES.—The agency shall pay for covered
 1683  services and procedures rendered to a Medicaid recipient by, or
 1684  under the personal supervision of, a person licensed under state
 1685  law to practice medicine or osteopathic medicine. These services
 1686  may be furnished in the physician’s office, the Medicaid
 1687  recipient’s home, a hospital, a nursing facility, or elsewhere,
 1688  but must shall be medically necessary for the treatment of a
 1689  covered an injury or, illness, or disease within the scope of
 1690  the practice of medicine or osteopathic medicine as defined by
 1691  state law. The agency may shall not pay for services that are
 1692  clinically unproven, experimental, or for purely cosmetic
 1693  purposes.
 1694         (10) PORTABLE X-RAY SERVICES.—The agency shall pay for
 1695  professional and technical portable radiological services
 1696  ordered by a licensed physician or other licensed health care
 1697  practitioner of the healing arts which are provided by a
 1698  licensed professional in a setting other than a hospital,
 1699  clinic, or office of a physician or practitioner of the healing
 1700  arts, on behalf of a recipient.
 1701         (11) RURAL HEALTH CLINIC SERVICES.—The agency shall pay for
 1702  outpatient primary health care services for a recipient provided
 1703  by a clinic certified by and participating in the Medicare
 1704  program which is located in a federally designated, rural,
 1705  medically underserved area and has on its staff one or more
 1706  licensed primary care nurse practitioners or physician
 1707  assistants, and a licensed staff supervising physician or a
 1708  consulting supervising physician.
 1709         (12) TRANSPORTATION SERVICES.—The agency shall ensure that
 1710  appropriate transportation services are available for a Medicaid
 1711  recipient in need of transport to a qualified Medicaid provider
 1712  for medically necessary and Medicaid-compensable services, if
 1713  the recipient’s provided a client’s ability to choose a specific
 1714  transportation provider is shall be limited to those options
 1715  resulting from policies established by the agency to meet the
 1716  fiscal limitations of the General Appropriations Act. The agency
 1717  may pay for necessary transportation and other related travel
 1718  expenses as necessary only if these services are not otherwise
 1719  available.
 1720         Section 24. Section 409.906, Florida Statutes, is amended
 1721  to read:
 1722         409.906 Optional Medicaid services.—Subject to specific
 1723  appropriations, the agency may make payments for services which
 1724  are optional to the state under Title XIX of the Social Security
 1725  Act and are furnished by Medicaid providers to recipients who
 1726  are determined to be eligible on the dates on which the services
 1727  were provided. Any optional service that is provided shall be
 1728  provided only when medically necessary and in accordance with
 1729  state and federal law. Optional services rendered by providers
 1730  in mobile units to Medicaid recipients may be restricted or
 1731  prohibited by the agency. Nothing in This section does not shall
 1732  be construed to prevent or limit the agency from adjusting fees,
 1733  reimbursement rates, lengths of stay, number of visits, or
 1734  number of services, or making any other adjustments necessary to
 1735  comply with the availability of moneys and any limitations or
 1736  directions provided for in the General Appropriations Act, or
 1737  chapter 216, or s. 409.9022. If necessary to safeguard the
 1738  state’s systems of providing services to elderly and disabled
 1739  persons and subject to the notice and review provisions of s.
 1740  216.177, the Governor may direct the Agency for Health Care
 1741  Administration to amend the Medicaid state plan to delete the
 1742  optional Medicaid service known as “Intermediate Care Facilities
 1743  for the Developmentally Disabled.” Optional services may
 1744  include:
 1745         (1) ADULT DENTAL SERVICES.—For a recipient who is 21 years
 1746  of age or older:
 1747         (a) The agency may pay for medically necessary, emergency
 1748  dental procedures to alleviate pain or infection. Emergency
 1749  dental care is shall be limited to emergency oral examinations,
 1750  necessary radiographs, extractions, and incision and drainage of
 1751  abscess, for a recipient who is 21 years of age or older.
 1752         (b) Beginning July 1, 2006, The agency may pay for full or
 1753  partial dentures, the procedures required to seat full or
 1754  partial dentures, and the repair and reline of full or partial
 1755  dentures, provided by or under the direction of a licensed
 1756  dentist, for a recipient who is 21 years of age or older.
 1757         (c) However, Medicaid will not provide reimbursement for
 1758  dental services provided in a mobile dental unit, except for a
 1759  mobile dental unit:
 1760         1. Owned by, operated by, or having a contractual agreement
 1761  with the Department of Health and complying with Medicaid’s
 1762  county health department clinic services program specifications
 1763  as a county health department clinic services provider.
 1764         2. Owned by, operated by, or having a contractual
 1765  arrangement with a federally qualified health center and
 1766  complying with Medicaid’s federally qualified health center
 1767  specifications as a federally qualified health center provider.
 1768         3. Rendering dental services to Medicaid recipients, 21
 1769  years of age and older, at nursing facilities.
 1770         4. Owned by, operated by, or having a contractual agreement
 1771  with a state-approved dental educational institution.
 1772         (2) ADULT HEALTH SCREENING SERVICES.—The agency may pay for
 1773  an annual routine physical examination, conducted by or under
 1774  the direction of a licensed physician, for a recipient age 21 or
 1775  older, without regard to medical necessity, in order to detect
 1776  and prevent disease, disability, or other health condition or
 1777  its progression.
 1778         (3) AMBULATORY SURGICAL CENTER SERVICES.—The agency may pay
 1779  for services provided to a recipient in an ambulatory surgical
 1780  center licensed under part I of chapter 395, by or under the
 1781  direction of a licensed physician or dentist.
 1782         (4) BIRTH CENTER SERVICES.—The agency may pay for
 1783  examinations and delivery, recovery, and newborn assessment, and
 1784  related services, provided in a licensed birth center staffed
 1785  with licensed physicians, certified nurse midwives, and midwives
 1786  licensed in accordance with chapter 467, to a recipient expected
 1787  to experience a low-risk pregnancy and delivery.
 1788         (5) CASE MANAGEMENT SERVICES.—The agency may pay for
 1789  primary care case management services rendered to a recipient
 1790  pursuant to a federally approved waiver, and targeted case
 1791  management services for specific groups of targeted recipients,
 1792  for which funding has been provided and which are rendered
 1793  pursuant to federal guidelines. The agency may is authorized to
 1794  limit reimbursement for targeted case management services in
 1795  order to comply with any limitations or directions provided for
 1796  in the General Appropriations Act.
 1797         (6) CHILDREN’S DENTAL SERVICES.—The agency may pay for
 1798  diagnostic, preventive, or corrective procedures, including
 1799  orthodontia in severe cases, provided to a recipient under age
 1800  21, by or under the supervision of a licensed dentist. Services
 1801  provided under this program include treatment of the teeth and
 1802  associated structures of the oral cavity, as well as treatment
 1803  of disease, injury, or impairment that may affect the oral or
 1804  general health of the individual. However, Medicaid may will not
 1805  provide reimbursement for dental services provided in a mobile
 1806  dental unit, except for a mobile dental unit:
 1807         (a) Owned by, operated by, or having a contractual
 1808  agreement with the Department of Health and complying with
 1809  Medicaid’s county health department clinic services program
 1810  specifications as a county health department clinic services
 1811  provider.
 1812         (b) Owned by, operated by, or having a contractual
 1813  arrangement with a federally qualified health center and
 1814  complying with Medicaid’s federally qualified health center
 1815  specifications as a federally qualified health center provider.
 1816         (c) Rendering dental services to Medicaid recipients, 21
 1817  years of age and older, at nursing facilities.
 1818         (d) Owned by, operated by, or having a contractual
 1819  agreement with a state-approved dental educational institution.
 1820         (7) CHIROPRACTIC SERVICES.—The agency may pay for manual
 1821  manipulation of the spine and initial services, screening, and X
 1822  rays provided to a recipient by a licensed chiropractic
 1823  physician.
 1824         (8) COMMUNITY MENTAL HEALTH SERVICES.—
 1825         (a) The agency may pay for rehabilitative services provided
 1826  to a recipient by a mental health or substance abuse provider
 1827  under contract with the agency or the Department of Children and
 1828  Family Services to provide such services. Those Services that
 1829  which are psychiatric in nature must shall be rendered or
 1830  recommended by a psychiatrist, and those services that which are
 1831  medical in nature must shall be rendered or recommended by a
 1832  physician or psychiatrist.
 1833         (a) The agency shall must develop a provider enrollment
 1834  process for community mental health providers which bases
 1835  provider enrollment on an assessment of service need. The
 1836  provider enrollment process shall be designed to control costs,
 1837  prevent fraud and abuse, consider provider expertise and
 1838  capacity, and assess provider success in managing utilization of
 1839  care and measuring treatment outcomes. Providers must will be
 1840  selected through a competitive procurement or selective
 1841  contracting process. In addition to other community mental
 1842  health providers, the agency shall consider enrolling for
 1843  enrollment mental health programs licensed under chapter 395 and
 1844  group practices licensed under chapter 458, chapter 459, chapter
 1845  490, or chapter 491. The agency may is also authorized to
 1846  continue the operation of its behavioral health utilization
 1847  management program and may develop new services, if these
 1848  actions are necessary, to ensure savings from the implementation
 1849  of the utilization management system. The agency shall
 1850  coordinate the implementation of this enrollment process with
 1851  the Department of Children and Family Services and the
 1852  Department of Juvenile Justice. The agency may use is authorized
 1853  to utilize diagnostic criteria in setting reimbursement rates,
 1854  to preauthorize certain high-cost or highly utilized services,
 1855  to limit or eliminate coverage for certain services, or to make
 1856  any other adjustments necessary to comply with any limitations
 1857  or directions provided for in the General Appropriations Act.
 1858         (b) The agency may is authorized to implement reimbursement
 1859  and use management reforms in order to comply with any
 1860  limitations or directions in the General Appropriations Act,
 1861  which may include, but are not limited to: prior authorization
 1862  of treatment and service plans; prior authorization of services;
 1863  enhanced use review programs for highly used services; and
 1864  limits on services for recipients those determined to be abusing
 1865  their benefit coverages.
 1866         (9) DIALYSIS FACILITY SERVICES.—Subject to specific
 1867  appropriations being provided for this purpose, the agency may
 1868  pay a dialysis facility that is approved as a dialysis facility
 1869  in accordance with Title XVIII of the Social Security Act, for
 1870  dialysis services that are provided to a Medicaid recipient
 1871  under the direction of a physician licensed to practice medicine
 1872  or osteopathic medicine in this state, including dialysis
 1873  services provided in the recipient’s home by a hospital-based or
 1874  freestanding dialysis facility.
 1875         (10) DURABLE MEDICAL EQUIPMENT.—The agency may authorize
 1876  and pay for certain durable medical equipment and supplies
 1877  provided to a Medicaid recipient as medically necessary.
 1878         (11) HEALTHY START SERVICES.—The agency may pay for a
 1879  continuum of risk-appropriate medical and psychosocial services
 1880  for the Healthy Start program in accordance with a federal
 1881  waiver. The agency may not implement the federal waiver unless
 1882  the waiver permits the state to limit enrollment or the amount,
 1883  duration, and scope of services to ensure that expenditures will
 1884  not exceed funds appropriated by the Legislature or available
 1885  from local sources. If the Health Care Financing Administration
 1886  does not approve a federal waiver for Healthy Start services is
 1887  not approved, the agency, in consultation with the Department of
 1888  Health and the Florida Association of Healthy Start Coalitions,
 1889  may is authorized to establish a Medicaid certified-match
 1890  program for Healthy Start services. Participation in the Healthy
 1891  Start certified-match program is shall be voluntary, and
 1892  reimbursement is shall be limited to the federal Medicaid share
 1893  provided to Medicaid-enrolled Healthy Start coalitions for
 1894  services provided to Medicaid recipients. The agency may not
 1895  shall take no action to implement a certified-match program
 1896  without ensuring that the amendment and review requirements of
 1897  ss. 216.177 and 216.181 have been met.
 1898         (12) HEARING SERVICES.—The agency may pay for hearing and
 1899  related services, including hearing evaluations, hearing aid
 1900  devices, dispensing of the hearing aid, and related repairs, if
 1901  provided to a recipient by a licensed hearing aid specialist,
 1902  otolaryngologist, otologist, audiologist, or physician.
 1903         (13) HOME AND COMMUNITY-BASED SERVICES.—
 1904         (a) The agency may pay for home-based or community-based
 1905  services that are rendered to a recipient in accordance with a
 1906  federally approved waiver program. The agency may limit or
 1907  eliminate coverage for certain services, preauthorize high-cost
 1908  or highly utilized services, or make any other adjustments
 1909  necessary to comply with any limitations or directions provided
 1910  for in the General Appropriations Act.
 1911         (b) The agency may consolidate types of services offered in
 1912  the Aged and Disabled Waiver, the Channeling Waiver, the Project
 1913  AIDS Care Waiver, and the Traumatic Brain and Spinal Cord Injury
 1914  Waiver programs in order to group similar services under a
 1915  single service, or continue a service upon evidence of the need
 1916  for including a particular service type in a particular waiver.
 1917  The agency may is authorized to seek a Medicaid state plan
 1918  amendment or federal waiver approval to implement this policy.
 1919         (c) The agency may implement a utilization management
 1920  program designed to prior-authorize home and community-based
 1921  service plans which and includes, but is not limited to,
 1922  assessing proposed quantity and duration of services and
 1923  monitoring ongoing service use by participants in the program.
 1924  The agency may is authorized to competitively procure a
 1925  qualified organization to provide utilization management of home
 1926  and community-based services. The agency may is authorized to
 1927  seek any federal waivers to implement this initiative.
 1928         (d) The agency shall assess a fee against the parents of a
 1929  child who is being served by a waiver under this subsection if
 1930  the adjusted household income is greater than 100 percent of the
 1931  federal poverty level. The amount of the fee shall be calculated
 1932  using a sliding scale based on the size of the family, the
 1933  amount of the parent’s adjusted gross income, and the federal
 1934  poverty guidelines. The agency shall seek a federal waiver to
 1935  implement this provision.
 1936         (14) HOSPICE CARE SERVICES.—The agency may pay for all
 1937  reasonable and necessary services for the palliation or
 1938  management of a recipient’s terminal illness, if the services
 1939  are provided by a hospice that is licensed under part IV of
 1940  chapter 400 and meets Medicare certification requirements.
 1941         (15) INTERMEDIATE CARE FACILITY FOR THE DEVELOPMENTALLY
 1942  DISABLED SERVICES.—The agency may pay for health-related care
 1943  and services provided on a 24-hour-a-day basis by a facility
 1944  licensed and certified as a Medicaid Intermediate Care Facility
 1945  for the Developmentally Disabled, for a recipient who needs such
 1946  care because of a developmental disability. Payment may shall
 1947  not include bed-hold days except in facilities with occupancy
 1948  rates of 95 percent or greater. The agency may is authorized to
 1949  seek any federal waiver approvals to implement this policy. If
 1950  necessary to safeguard the state’s systems of providing services
 1951  to elderly and disabled persons and subject to notice and review
 1952  under s. 216.177, the Governor may direct the agency to amend
 1953  the Medicaid state plan to delete these services.
 1954         (16) INTERMEDIATE CARE SERVICES.—The agency may pay for 24
 1955  hour-a-day intermediate care nursing and rehabilitation services
 1956  rendered to a recipient in a nursing facility licensed under
 1957  part II of chapter 400, if the services are ordered by and
 1958  provided under the direction of a physician.
 1959         (17) OPTOMETRIC SERVICES.—The agency may pay for services
 1960  provided to a recipient, including examination, diagnosis,
 1961  treatment, and management, related to ocular pathology, if the
 1962  services are provided by a licensed optometrist or physician.
 1963         (18) PHYSICIAN ASSISTANT SERVICES.—The agency may pay for
 1964  all services provided to a recipient by a physician assistant
 1965  licensed under s. 458.347 or s. 459.022. Reimbursement for such
 1966  services must be at least not less than 80 percent of the
 1967  reimbursement that would be paid to a physician who provided the
 1968  same services.
 1969         (19) PODIATRIC SERVICES.—The agency may pay for services,
 1970  including diagnosis and medical, surgical, palliative, and
 1971  mechanical treatment, related to ailments of the human foot and
 1972  lower leg, if provided to a recipient by a podiatric physician
 1973  licensed under state law.
 1974         (20) PRESCRIBED DRUG SERVICES.—The agency may pay for
 1975  medications that are prescribed for a recipient by a physician
 1976  or other licensed health care practitioner of the healing arts
 1977  authorized to prescribe medications and that are dispensed to
 1978  the recipient by a licensed pharmacist or physician in
 1979  accordance with applicable state and federal law. However, the
 1980  agency may not pay for any psychotropic medication prescribed
 1981  for a child younger than the age for which the federal Food and
 1982  Drug Administration has approved its use.
 1983         (21) REGISTERED NURSE FIRST ASSISTANT SERVICES.—The agency
 1984  may pay for all services provided to a recipient by a registered
 1985  nurse first assistant as described in s. 464.027. Reimbursement
 1986  for such services must be at least may not be less than 80
 1987  percent of the reimbursement that would be paid to a physician
 1988  providing the same services.
 1989         (22) STATE HOSPITAL SERVICES.—The agency may pay for all
 1990  inclusive psychiatric inpatient hospital care provided to a
 1991  recipient age 65 or older in a state mental hospital.
 1992         (23) VISUAL SERVICES.—The agency may pay for visual
 1993  examinations, eyeglasses, and eyeglass repairs for a recipient
 1994  if they are prescribed by a licensed physician specializing in
 1995  diseases of the eye or by a licensed optometrist. Eyeglass
 1996  frames for adult recipients are shall be limited to one pair per
 1997  recipient every 2 years, except a second pair may be provided
 1998  during that period after prior authorization. Eyeglass lenses
 1999  for adult recipients are shall be limited to one pair per year
 2000  except a second pair may be provided during that period after
 2001  prior authorization.
 2002         (24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.—The agency for
 2003  Health Care Administration, in consultation with the Department
 2004  of Children and Family Services, may establish a targeted case
 2005  management project in those counties identified by the
 2006  department of Children and Family Services and for all counties
 2007  with a community-based child welfare project, as authorized
 2008  under s. 409.1671, which have been specifically approved by the
 2009  department. The covered group that is of individuals who are
 2010  eligible for to receive targeted case management include
 2011  children who are eligible for Medicaid; who are between the ages
 2012  of birth through 21; and who are under protective supervision or
 2013  postplacement supervision, under foster-care supervision, or in
 2014  shelter care or foster care. The number of eligible children
 2015  individuals who are eligible to receive targeted case management
 2016  is limited to the number for whom the department of Children and
 2017  Family Services has matching funds to cover the costs. The
 2018  general revenue funds required to match the funds for services
 2019  provided by the community-based child welfare projects are
 2020  limited to funds available for services described under s.
 2021  409.1671. The department of Children and Family Services may
 2022  transfer the general revenue matching funds as billed by the
 2023  agency for Health Care Administration.
 2024         (25) ASSISTIVE-CARE SERVICES.—The agency may pay for
 2025  assistive-care services provided to recipients with functional
 2026  or cognitive impairments residing in assisted living facilities,
 2027  adult family-care homes, or residential treatment facilities.
 2028  These services may include health support, assistance with the
 2029  activities of daily living and the instrumental acts of daily
 2030  living, assistance with medication administration, and
 2031  arrangements for health care.
 2032         (26) HOME AND COMMUNITY-BASED SERVICES FOR AUTISM SPECTRUM
 2033  DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.—The agency may is
 2034  authorized to seek federal approval through a Medicaid waiver or
 2035  a state plan amendment for the provision of occupational
 2036  therapy, speech therapy, physical therapy, behavior analysis,
 2037  and behavior assistant services to individuals who are 5 years
 2038  of age and under and have a diagnosed developmental disability
 2039  as defined in s. 393.063, or autism spectrum disorder as defined
 2040  in s. 627.6686, or Down syndrome, a genetic disorder caused by
 2041  the presence of extra chromosomal material on chromosome 21.
 2042  Causes of the syndrome may include Trisomy 21, Mosaicism,
 2043  Robertsonian Translocation, and other duplications of a portion
 2044  of chromosome 21. Coverage for such services is shall be limited
 2045  to $36,000 annually and may not exceed $108,000 in total
 2046  lifetime benefits. The agency shall submit an annual report
 2047  beginning on January 1, 2009, to the President of the Senate,
 2048  the Speaker of the House of Representatives, and the relevant
 2049  committees of the Senate and the House of Representatives
 2050  regarding progress on obtaining federal approval and
 2051  recommendations for the implementation of these home and
 2052  community-based services. The agency may not implement this
 2053  subsection without prior legislative approval.
 2054         (27) ANESTHESIOLOGIST ASSISTANT SERVICES.—The agency may
 2055  pay for all services provided to a recipient by an
 2056  anesthesiologist assistant licensed under s. 458.3475 or s.
 2057  459.023. Reimbursement for such services must be at least not
 2058  less than 80 percent of the reimbursement that would be paid to
 2059  a physician who provided the same services.
 2060         Section 25. Section 409.9062, Florida Statutes, is amended
 2061  to read:
 2062         409.9062 Lung transplant services for Medicaid recipients.
 2063  Subject to the availability of funds and subject to any
 2064  limitations or directions provided for in the General
 2065  Appropriations Act, or chapter 216, or s. 409.9022, the Agency
 2066  for Health Care Administration Medicaid program shall pay for
 2067  medically necessary lung transplant services for Medicaid
 2068  recipients. These payments must be used to reimburse approved
 2069  lung transplant facilities a global fee for providing lung
 2070  transplant services to Medicaid recipients.
 2071         Section 26. Paragraph (h) of subsection (3) of section
 2072  409.907, Florida Statutes, is amended to read:
 2073         409.907 Medicaid provider agreements.—The agency may make
 2074  payments for medical assistance and related services rendered to
 2075  Medicaid recipients only to an individual or entity who has a
 2076  provider agreement in effect with the agency, who is performing
 2077  services or supplying goods in accordance with federal, state,
 2078  and local law, and who agrees that no person shall, on the
 2079  grounds of handicap, race, color, or national origin, or for any
 2080  other reason, be subjected to discrimination under any program
 2081  or activity for which the provider receives payment from the
 2082  agency.
 2083         (3) The provider agreement developed by the agency, in
 2084  addition to the requirements specified in subsections (1) and
 2085  (2), shall require the provider to:
 2086         (h) Be liable for and indemnify, defend, and hold the
 2087  agency harmless from all claims, suits, judgments, or damages,
 2088  including court costs and attorney’s fees, arising out of the
 2089  negligence or omissions of the provider in the course of
 2090  providing services to a recipient or a person believed to be a
 2091  recipient, subject to s. 766.1183 or s. 766.1184.
 2092         Section 27. Section 409.908, Florida Statutes, is amended
 2093  to read:
 2094         409.908 Reimbursement of Medicaid providers.—Subject to
 2095  specific appropriations, the agency shall reimburse Medicaid
 2096  providers, in accordance with state and federal law, according
 2097  to methodologies set forth in the rules of the agency and in
 2098  policy manuals and handbooks incorporated by reference therein.
 2099  These methodologies may include fee schedules, reimbursement
 2100  methods based on cost reporting, negotiated fees, competitive
 2101  bidding pursuant to s. 287.057, and other mechanisms the agency
 2102  considers efficient and effective for purchasing services or
 2103  goods on behalf of recipients. If a provider is reimbursed based
 2104  on cost reporting and submits a cost report late and that cost
 2105  report would have been used to set a lower reimbursement rate
 2106  for a rate semester, then the provider’s rate for that semester
 2107  shall be retroactively calculated using the new cost report, and
 2108  full payment at the recalculated rate shall be effected
 2109  retroactively. Medicare-granted extensions for filing cost
 2110  reports, if applicable, shall also apply to Medicaid cost
 2111  reports. Payment for Medicaid compensable services made on
 2112  behalf of Medicaid eligible persons is subject to the
 2113  availability of moneys and any limitations or directions
 2114  provided for in the General Appropriations Act, or chapter 216,
 2115  or s. 409.9022. Further, nothing in This section does not shall
 2116  be construed to prevent or limit the agency from adjusting fees,
 2117  reimbursement rates, lengths of stay, number of visits, or
 2118  number of services, or making any other adjustments necessary to
 2119  comply with the availability of moneys and any limitations or
 2120  directions provided for in the General Appropriations Act if,
 2121  provided the adjustment is consistent with legislative intent.
 2122         (1) HOSPITAL SERVICES.Reimbursement to hospitals licensed
 2123  under part I of chapter 395 must be made prospectively or on the
 2124  basis of negotiation.
 2125         (a) Inpatient care.
 2126         1. Reimbursement for inpatient care is limited as provided
 2127  for in s. 409.905(5), except for:
 2128         a.1. The raising of rate reimbursement caps, excluding
 2129  rural hospitals.
 2130         b.2. Recognition of the costs of graduate medical
 2131  education.
 2132         c.3. Other methodologies recognized in the General
 2133  Appropriations Act.
 2134         2.If During the years funds are transferred from the
 2135  Department of Health, any reimbursement supported by such funds
 2136  is shall be subject to certification by the Department of Health
 2137  that the hospital has complied with s. 381.0403. The agency may
 2138  is authorized to receive funds from state entities, including,
 2139  but not limited to, the Department of Health, local governments,
 2140  and other local political subdivisions, for the purpose of
 2141  making special exception payments, including federal matching
 2142  funds, through the Medicaid inpatient reimbursement
 2143  methodologies. Funds received from state entities or local
 2144  governments for this purpose shall be separately accounted for
 2145  and may shall not be commingled with other state or local funds
 2146  in any manner. The agency may certify all local governmental
 2147  funds used as state match under Title XIX of the Social Security
 2148  Act, to the extent that the identified local health care
 2149  provider that is otherwise entitled to and is contracted to
 2150  receive such local funds is the benefactor under the state’s
 2151  Medicaid program as determined under the General Appropriations
 2152  Act and pursuant to an agreement between the agency for Health
 2153  Care Administration and the local governmental entity. The local
 2154  governmental entity shall use a certification form prescribed by
 2155  the agency. At a minimum, the certification form must shall
 2156  identify the amount being certified and describe the
 2157  relationship between the certifying local governmental entity
 2158  and the local health care provider. The agency shall prepare an
 2159  annual statement of impact which documents the specific
 2160  activities undertaken during the previous fiscal year pursuant
 2161  to this paragraph, to be submitted to the Legislature annually
 2162  by no later than January 1, annually.
 2163         (b) Outpatient care.
 2164         1. Reimbursement for hospital outpatient care is limited to
 2165  $1,500 per state fiscal year per recipient, except for:
 2166         a.1.Such Care provided to a Medicaid recipient under age
 2167  21, in which case the only limitation is medical necessity.
 2168         b.2. Renal dialysis services.
 2169         c.3. Other exceptions made by the agency.
 2170         2. The agency may is authorized to receive funds from state
 2171  entities, including, but not limited to, the Department of
 2172  Health, the Board of Governors of the State University System,
 2173  local governments, and other local political subdivisions, for
 2174  the purpose of making payments, including federal matching
 2175  funds, through the Medicaid outpatient reimbursement
 2176  methodologies. Funds received from state entities and local
 2177  governments for this purpose shall be separately accounted for
 2178  and may shall not be commingled with other state or local funds
 2179  in any manner.
 2180         3. The agency may limit inflationary increases for
 2181  outpatient hospital services as directed by the General
 2182  Appropriations Act.
 2183         (c) Disproportionate share.Hospitals that provide services
 2184  to a disproportionate share of low-income Medicaid recipients,
 2185  or that participate in the regional perinatal intensive care
 2186  center program under chapter 383, or that participate in the
 2187  statutory teaching hospital disproportionate share program may
 2188  receive additional reimbursement. The total amount of payment
 2189  for disproportionate share hospitals shall be fixed by the
 2190  General Appropriations Act. The computation of these payments
 2191  must comply be made in compliance with all federal regulations
 2192  and the methodologies described in ss. 409.911, 409.9112, and
 2193  409.9113.
 2194         (d) The agency is authorized to limit inflationary
 2195  increases for outpatient hospital services as directed by the
 2196  General Appropriations Act.
 2197         (2) NURSING HOME CARE.
 2198         (a)1. Reimbursement to nursing homes licensed under part II
 2199  of chapter 400 and state-owned-and-operated intermediate care
 2200  facilities for the developmentally disabled licensed under part
 2201  VIII of chapter 400 must be made prospectively.
 2202         (a)2. Unless otherwise limited or directed in the General
 2203  Appropriations Act, reimbursement to hospitals licensed under
 2204  part I of chapter 395 for the provision of swing-bed nursing
 2205  home services must be based made on the basis of the average
 2206  statewide nursing home payment, and reimbursement to a hospital
 2207  licensed under part I of chapter 395 for the provision of
 2208  skilled nursing services must be based made on the basis of the
 2209  average nursing home payment for those services in the county in
 2210  which the hospital is located. If When a hospital is located in
 2211  a county that does not have any community nursing homes,
 2212  reimbursement shall be determined by averaging the nursing home
 2213  payments in counties that surround the county in which the
 2214  hospital is located. Reimbursement to hospitals, including
 2215  Medicaid payment of Medicare copayments, for skilled nursing
 2216  services is shall be limited to 30 days, unless a prior
 2217  authorization has been obtained from the agency. Medicaid
 2218  reimbursement may be extended by the agency beyond 30 days, and
 2219  approval must be based upon verification by the patient’s
 2220  physician that the patient requires short-term rehabilitative
 2221  and recuperative services only, in which case an extension of no
 2222  more than 15 days may be approved. Reimbursement to a hospital
 2223  licensed under part I of chapter 395 for the temporary provision
 2224  of skilled nursing services to nursing home residents who have
 2225  been displaced as the result of a natural disaster or other
 2226  emergency may not exceed the average county nursing home payment
 2227  for those services in the county in which the hospital is
 2228  located and is limited to the period of time which the agency
 2229  considers necessary for continued placement of the nursing home
 2230  residents in the hospital.
 2231         (b) Subject to any limitations or directions provided for
 2232  in the General Appropriations Act, the agency shall establish
 2233  and implement a Florida Title XIX Long-Term Care Reimbursement
 2234  Plan (Medicaid) for nursing home care in order to provide care
 2235  and services that conform to in conformance with the applicable
 2236  state and federal laws, rules, regulations, and quality and
 2237  safety standards and to ensure that individuals eligible for
 2238  medical assistance have reasonable geographic access to such
 2239  care.
 2240         1. The agency shall amend the long-term care reimbursement
 2241  plan and cost reporting system to create direct care and
 2242  indirect care subcomponents of the patient care component of the
 2243  per diem rate. These two subcomponents together must shall equal
 2244  the patient care component of the per diem rate. Separate cost
 2245  based ceilings shall be calculated for each patient care
 2246  subcomponent. The direct care subcomponent of the per diem rate
 2247  is shall be limited by the cost-based class ceiling, and the
 2248  indirect care subcomponent may be limited by the lower of the
 2249  cost-based class ceiling, the target rate class ceiling, or the
 2250  individual provider target.
 2251         2. The direct care subcomponent includes shall include
 2252  salaries and benefits of direct care staff providing nursing
 2253  services, including registered nurses, licensed practical
 2254  nurses, and certified nursing assistants who deliver care
 2255  directly to residents in the nursing home facility. This
 2256  excludes nursing administration, minimum data set, and care plan
 2257  coordinators, staff development, and the staffing coordinator.
 2258  The direct care subcomponent also includes medically necessary
 2259  dental care, vision care, hearing care, and podiatric care.
 2260         3. All other patient care costs are shall be included in
 2261  the indirect care cost subcomponent of the patient care per diem
 2262  rate. There shall be no Costs may not be directly or indirectly
 2263  allocated to the direct care subcomponent from a home office or
 2264  management company.
 2265         4. On July 1 of each year, the agency shall report to the
 2266  Legislature direct and indirect care costs, including average
 2267  direct and indirect care costs per resident per facility and
 2268  direct care and indirect care salaries and benefits per category
 2269  of staff member per facility.
 2270         5. In order to offset the cost of general and professional
 2271  liability insurance, the agency shall amend the plan to allow
 2272  for interim rate adjustments to reflect increases in the cost of
 2273  general or professional liability insurance for nursing homes.
 2274  This provision shall be implemented to the extent existing
 2275  appropriations are available.
 2276  
 2277  It is the intent of the Legislature that the reimbursement plan
 2278  achieve the goal of providing access to health care for nursing
 2279  home residents who require large amounts of care while
 2280  encouraging diversion services as an alternative to nursing home
 2281  care for residents who can be served within the community. The
 2282  agency shall base the establishment of any maximum rate of
 2283  payment, whether overall or component, on the available moneys
 2284  as provided for in the General Appropriations Act. The agency
 2285  may base the maximum rate of payment on the results of
 2286  scientifically valid analysis and conclusions derived from
 2287  objective statistical data pertinent to the particular maximum
 2288  rate of payment.
 2289         (c) The agency shall request and implement Medicaid waivers
 2290  approved by the federal Centers for Medicare and Medicaid
 2291  Services to advance and treat a portion of the Medicaid nursing
 2292  home per diem as capital for creating and operating a risk
 2293  retention group for self-insurance purposes, consistent with
 2294  federal and state laws and rules.
 2295         (3) FEE-FOR-SERVICE REIMBURSEMENT.Subject to any
 2296  limitations or directions provided for in the General
 2297  Appropriations Act, the following Medicaid services and goods
 2298  may be reimbursed on a fee-for-service basis. For each allowable
 2299  service or goods furnished in accordance with Medicaid rules,
 2300  policy manuals, handbooks, and state and federal law, the
 2301  payment shall be the amount billed by the provider, the
 2302  provider’s usual and customary charge, or the maximum allowable
 2303  fee established by the agency, whichever amount is less, with
 2304  the exception of those services or goods for which the agency
 2305  makes payment using a methodology based on capitation rates,
 2306  average costs, or negotiated fees.
 2307         (a) Advanced registered nurse practitioner services.
 2308         (b) Birth center services.
 2309         (c) Chiropractic services.
 2310         (d) Community mental health services.
 2311         (e) Dental services, including oral and maxillofacial
 2312  surgery.
 2313         (f) Durable medical equipment.
 2314         (g) Hearing services.
 2315         (h) Occupational therapy for Medicaid recipients under age
 2316  21.
 2317         (i) Optometric services.
 2318         (j) Orthodontic services.
 2319         (k) Personal care for Medicaid recipients under age 21.
 2320         (l) Physical therapy for Medicaid recipients under age 21.
 2321         (m) Physician assistant services.
 2322         (n) Podiatric services.
 2323         (o) Portable X-ray services.
 2324         (p) Private-duty nursing for Medicaid recipients under age
 2325  21.
 2326         (q) Registered nurse first assistant services.
 2327         (r) Respiratory therapy for Medicaid recipients under age
 2328  21.
 2329         (s) Speech therapy for Medicaid recipients under age 21.
 2330         (t) Visual services.
 2331         (4) MANAGED CARE SERVICES.Subject to any limitations or
 2332  directions provided for in the General Appropriations Act,
 2333  alternative health plans, health maintenance organizations, and
 2334  prepaid health plans shall be reimbursed a fixed, prepaid amount
 2335  negotiated, or competitively bid pursuant to s. 287.057, by the
 2336  agency and prospectively paid to the provider monthly for each
 2337  Medicaid recipient enrolled. The amount may not exceed the
 2338  average amount the agency determines it would have paid, based
 2339  on claims experience, for recipients in the same or similar
 2340  category of eligibility. The agency shall calculate capitation
 2341  rates on a regional basis and, beginning September 1, 1995,
 2342  shall include age-band differentials in such calculations.
 2343         (5) AMBULATORY SURGICAL CENTERS.An ambulatory surgical
 2344  center shall be reimbursed the lesser of the amount billed by
 2345  the provider or the Medicare-established allowable amount for
 2346  the facility.
 2347         (6) EPSDT SERVICES.A provider of early and periodic
 2348  screening, diagnosis, and treatment services to Medicaid
 2349  recipients who are children under age 21 shall be reimbursed
 2350  using an all-inclusive rate stipulated in a fee schedule
 2351  established by the agency. A provider of the visual, dental, and
 2352  hearing components of such services shall be reimbursed the
 2353  lesser of the amount billed by the provider or the Medicaid
 2354  maximum allowable fee established by the agency.
 2355         (7) FAMILY PLANNING SERVICES.A provider of family planning
 2356  services shall be reimbursed the lesser of the amount billed by
 2357  the provider or an all-inclusive amount per type of visit for
 2358  physicians and advanced registered nurse practitioners, as
 2359  established by the agency in a fee schedule.
 2360         (8) HOME OR COMMUNITY-BASED SERVICES.A provider of home
 2361  based or community-based services rendered pursuant to a
 2362  federally approved waiver shall be reimbursed based on an
 2363  established or negotiated rate for each service. These rates
 2364  shall be established according to an analysis of the expenditure
 2365  history and prospective budget developed by each contract
 2366  provider participating in the waiver program, or under any other
 2367  methodology adopted by the agency and approved by the Federal
 2368  Government in accordance with the waiver. Privately owned and
 2369  operated community-based residential facilities that which meet
 2370  agency requirements and which formerly received Medicaid
 2371  reimbursement for the optional intermediate care facility for
 2372  the mentally retarded service may participate in the
 2373  developmental services waiver as part of a home-and-community
 2374  based continuum of care for Medicaid recipients who receive
 2375  waiver services.
 2376         (9) HOME HEALTH SERVICES AND MEDICAL SUPPLIES.A provider
 2377  of home health care services or of medical supplies and
 2378  appliances shall be reimbursed on the basis of competitive
 2379  bidding or for the lesser of the amount billed by the provider
 2380  or the agency’s established maximum allowable amount, except
 2381  that, in the case of the rental of durable medical equipment,
 2382  the total rental payments for durable medical equipment may not
 2383  exceed the purchase price of the equipment over its expected
 2384  useful life or the agency’s established maximum allowable
 2385  amount, whichever amount is less.
 2386         (10) HOSPICE.A hospice shall be reimbursed through a
 2387  prospective system for each Medicaid hospice patient at Medicaid
 2388  rates using the methodology established for hospice
 2389  reimbursement pursuant to Title XVIII of the federal Social
 2390  Security Act.
 2391         (11) LABORATORY SERVICES.A provider of independent
 2392  laboratory services shall be reimbursed on the basis of
 2393  competitive bidding or for the least of the amount billed by the
 2394  provider, the provider’s usual and customary charge, or the
 2395  Medicaid maximum allowable fee established by the agency.
 2396         (12) PHYSICIAN SERVICES.
 2397         (a) A physician shall be reimbursed the lesser of the
 2398  amount billed by the provider or the Medicaid maximum allowable
 2399  fee established by the agency.
 2400         (b) The agency shall adopt a fee schedule, subject to any
 2401  limitations or directions provided for in the General
 2402  Appropriations Act, based on a resource-based relative value
 2403  scale for pricing Medicaid physician services. Under the this
 2404  fee schedule, physicians shall be paid a dollar amount for each
 2405  service based on the average resources required to provide the
 2406  service, including, but not limited to, estimates of average
 2407  physician time and effort, practice expense, and the costs of
 2408  professional liability insurance. The fee schedule must shall
 2409  provide increased reimbursement for preventive and primary care
 2410  services and lowered reimbursement for specialty services by
 2411  using at least two conversion factors, one for cognitive
 2412  services and another for procedural services. The fee schedule
 2413  may shall not increase total Medicaid physician expenditures
 2414  unless moneys are available. The agency for Health Care
 2415  Administration shall seek the advice of a 16-member advisory
 2416  panel in formulating and adopting the fee schedule. The panel
 2417  shall consist of Medicaid physicians licensed under chapters 458
 2418  and 459 and shall be composed of 50 percent primary care
 2419  physicians and 50 percent specialty care physicians.
 2420         (c) Notwithstanding paragraph (b), reimbursement fees to
 2421  physicians for providing total obstetrical services to Medicaid
 2422  recipients, which include prenatal, delivery, and postpartum
 2423  care, must shall be at least $1,500 per delivery for a pregnant
 2424  woman with low medical risk and at least $2,000 per delivery for
 2425  a pregnant woman with high medical risk. However, reimbursement
 2426  to physicians working in regional perinatal intensive care
 2427  centers designated pursuant to chapter 383, for services to
 2428  certain pregnant Medicaid recipients with a high medical risk,
 2429  may be made according to obstetrical care and neonatal care
 2430  groupings and rates established by the agency. Nurse midwives
 2431  licensed under part I of chapter 464 or midwives licensed under
 2432  chapter 467 shall be reimbursed at least no less than 80 percent
 2433  of the low medical risk fee. The agency shall by rule determine,
 2434  for the purpose of this paragraph, what constitutes a high or
 2435  low medical risk pregnant woman and may shall not pay more based
 2436  solely on the fact that a caesarean section was performed,
 2437  rather than a vaginal delivery. The agency shall by rule
 2438  determine a prorated payment for obstetrical services in cases
 2439  where only part of the total prenatal, delivery, or postpartum
 2440  care was performed. The Department of Health shall adopt rules
 2441  for appropriate insurance coverage for midwives licensed under
 2442  chapter 467. Before issuing and renewing Prior to the issuance
 2443  and renewal of an active license, or reactivating reactivation
 2444  of an inactive license for midwives licensed under chapter 467,
 2445  such licensees must shall submit proof of coverage with each
 2446  application.
 2447         (d) Effective January 1, 2013, Medicaid fee-for-service
 2448  payments to primary care physicians for primary care services
 2449  must be at least 100 percent of the Medicare payment rate for
 2450  such services.
 2451         (13) DUALLY ELIGIBLE RECIPIENTS.Medicare premiums for
 2452  persons eligible for both Medicare and Medicaid coverage shall
 2453  be paid at the rates established by Title XVIII of the Social
 2454  Security Act. For Medicare services rendered to Medicaid
 2455  eligible persons, Medicaid shall pay Medicare deductibles and
 2456  coinsurance as follows:
 2457         (a) Medicaid’s financial obligation for deductibles and
 2458  coinsurance payments shall be based on Medicare allowable fees,
 2459  not on a provider’s billed charges.
 2460         (b) Medicaid may not will pay any no portion of Medicare
 2461  deductibles and coinsurance if when payment that Medicare has
 2462  made for the service equals or exceeds what Medicaid would have
 2463  paid if it had been the sole payor. The combined payment of
 2464  Medicare and Medicaid may shall not exceed the amount Medicaid
 2465  would have paid had it been the sole payor. The Legislature
 2466  finds that there has been confusion regarding the reimbursement
 2467  for services rendered to dually eligible Medicare beneficiaries.
 2468  Accordingly, the Legislature clarifies that it has always been
 2469  the intent of the Legislature before and after 1991 that, in
 2470  reimbursing in accordance with fees established by Title XVIII
 2471  for premiums, deductibles, and coinsurance for Medicare services
 2472  rendered by physicians to Medicaid eligible persons, physicians
 2473  be reimbursed at the lesser of the amount billed by the
 2474  physician or the Medicaid maximum allowable fee established by
 2475  the agency for Health Care Administration, as is permitted by
 2476  federal law. It has never been the intent of the Legislature
 2477  with regard to such services rendered by physicians that
 2478  Medicaid be required to provide any payment for deductibles,
 2479  coinsurance, or copayments for Medicare cost sharing, or any
 2480  expenses incurred relating thereto, in excess of the payment
 2481  amount provided for under the State Medicaid plan for physician
 2482  services such service. This payment methodology is applicable
 2483  even in those situations in which the payment for Medicare cost
 2484  sharing for a qualified Medicare beneficiary with respect to an
 2485  item or service is reduced or eliminated. This expression of the
 2486  Legislature clarifies is in clarification of existing law and
 2487  applies shall apply to payment for, and with respect to provider
 2488  agreements with respect to, items or services furnished on or
 2489  after July 1, 2000 the effective date of this act. This
 2490  paragraph applies to payment by Medicaid for items and services
 2491  furnished before July 1, 2000, the effective date of this act if
 2492  such payment is the subject of a lawsuit that is based on the
 2493  provisions of this section, and that is pending as of, or is
 2494  initiated after that date, the effective date of this act.
 2495         (c) Notwithstanding paragraphs (a) and (b):
 2496         1. Medicaid payments for Nursing Home Medicare part A
 2497  coinsurance are limited to the Medicaid nursing home per diem
 2498  rate less any amounts paid by Medicare, but only up to the
 2499  amount of Medicare coinsurance. The Medicaid per diem rate is
 2500  shall be the rate in effect for the dates of service of the
 2501  crossover claims and may not be subsequently adjusted due to
 2502  subsequent per diem rate adjustments.
 2503         2. Medicaid shall pay all deductibles and coinsurance for
 2504  Medicare-eligible recipients receiving freestanding end stage
 2505  renal dialysis center services.
 2506         3. Medicaid payments for general and specialty hospital
 2507  inpatient services are limited to the Medicare deductible and
 2508  coinsurance per spell of illness. Medicaid payments for hospital
 2509  Medicare Part A coinsurance are shall be limited to the Medicaid
 2510  hospital per diem rate less any amounts paid by Medicare, but
 2511  only up to the amount of Medicare coinsurance. Medicaid payments
 2512  for coinsurance are shall be limited to the Medicaid per diem
 2513  rate in effect for the dates of service of the crossover claims
 2514  and may not be subsequently adjusted due to subsequent per diem
 2515  adjustments.
 2516         4. Medicaid shall pay all deductibles and coinsurance for
 2517  Medicare emergency transportation services provided by
 2518  ambulances licensed pursuant to chapter 401.
 2519         5. Medicaid shall pay all deductibles and coinsurance for
 2520  portable X-ray Medicare Part B services provided in a nursing
 2521  home.
 2522         (14) PRESCRIBED DRUGS.A provider of prescribed drugs shall
 2523  be reimbursed the least of the amount billed by the provider,
 2524  the provider’s usual and customary charge, or the Medicaid
 2525  maximum allowable fee established by the agency, plus a
 2526  dispensing fee. The Medicaid maximum allowable fee for
 2527  ingredient cost must will be based on the lower of the: average
 2528  wholesale price (AWP) minus 16.4 percent, wholesaler acquisition
 2529  cost (WAC) plus 4.75 percent, the federal upper limit (FUL), the
 2530  state maximum allowable cost (SMAC), or the usual and customary
 2531  (UAC) charge billed by the provider.
 2532         (a) Medicaid providers must are required to dispense
 2533  generic drugs if available at lower cost and the agency has not
 2534  determined that the branded product is more cost-effective,
 2535  unless the prescriber has requested and received approval to
 2536  require the branded product.
 2537         (b) The agency shall is directed to implement a variable
 2538  dispensing fee for payments for prescribed medicines while
 2539  ensuring continued access for Medicaid recipients. The variable
 2540  dispensing fee may be based upon, but not limited to, either or
 2541  both the volume of prescriptions dispensed by a specific
 2542  pharmacy provider, the volume of prescriptions dispensed to an
 2543  individual recipient, and dispensing of preferred-drug-list
 2544  products.
 2545         (c) The agency may increase the pharmacy dispensing fee
 2546  authorized by statute and in the annual General Appropriations
 2547  Act by $0.50 for the dispensing of a Medicaid preferred-drug
 2548  list product and reduce the pharmacy dispensing fee by $0.50 for
 2549  the dispensing of a Medicaid product that is not included on the
 2550  preferred drug list.
 2551         (d) The agency may establish a supplemental pharmaceutical
 2552  dispensing fee to be paid to providers returning unused unit
 2553  dose packaged medications to stock and crediting the Medicaid
 2554  program for the ingredient cost of those medications if the
 2555  ingredient costs to be credited exceed the value of the
 2556  supplemental dispensing fee.
 2557         (e) The agency may is authorized to limit reimbursement for
 2558  prescribed medicine in order to comply with any limitations or
 2559  directions provided for in the General Appropriations Act, which
 2560  may include implementing a prospective or concurrent utilization
 2561  review program.
 2562         (15) PRIMARY CARE CASE MANAGEMENT.A provider of primary
 2563  care case management services rendered pursuant to a federally
 2564  approved waiver shall be reimbursed by payment of a fixed,
 2565  prepaid monthly sum for each Medicaid recipient enrolled with
 2566  the provider.
 2567         (16) RURAL HEALTH CLINICS.A provider of rural health
 2568  clinic services and federally qualified health center services
 2569  shall be reimbursed a rate per visit based on total reasonable
 2570  costs of the clinic, as determined by the agency in accordance
 2571  with federal regulations.
 2572         (17) TARGETED CASE MANAGEMENT.A provider of targeted case
 2573  management services shall be reimbursed pursuant to an
 2574  established fee, except where the Federal Government requires a
 2575  public provider be reimbursed on the basis of average actual
 2576  costs.
 2577         (18) TRANSPORTATION.Unless otherwise provided for in the
 2578  General Appropriations Act, a provider of transportation
 2579  services shall be reimbursed the lesser of the amount billed by
 2580  the provider or the Medicaid maximum allowable fee established
 2581  by the agency, except if when the agency has entered into a
 2582  direct contract with the provider, or with a community
 2583  transportation coordinator, for the provision of an all
 2584  inclusive service, or if when services are provided pursuant to
 2585  an agreement negotiated between the agency and the provider. The
 2586  agency, as provided for in s. 427.0135, shall purchase
 2587  transportation services through the community coordinated
 2588  transportation system, if available, unless the agency, after
 2589  consultation with the commission, determines that it cannot
 2590  reach mutually acceptable contract terms with the commission.
 2591  The agency may then contract for the same transportation
 2592  services provided in a more cost-effective manner and of
 2593  comparable or higher quality and standards. Nothing in
 2594         (a) This subsection does not shall be construed to limit or
 2595  preclude the agency from contracting for services using a
 2596  prepaid capitation rate or from establishing maximum fee
 2597  schedules, individualized reimbursement policies by provider
 2598  type, negotiated fees, prior authorization, competitive bidding,
 2599  increased use of mass transit, or any other mechanism that the
 2600  agency considers efficient and effective for the purchase of
 2601  services on behalf of Medicaid clients, including implementing a
 2602  transportation eligibility process.
 2603         (b) The agency may shall not be required to contract with
 2604  any community transportation coordinator or transportation
 2605  operator that has been determined by the agency, the Department
 2606  of Legal Affairs Medicaid Fraud Control Unit, or any other state
 2607  or federal agency to have engaged in any abusive or fraudulent
 2608  billing activities.
 2609         (c) The agency shall is authorized to competitively procure
 2610  transportation services or make other changes necessary to
 2611  secure approval of federal waivers needed to permit federal
 2612  financing of Medicaid transportation services at the service
 2613  matching rate rather than the administrative matching rate.
 2614  Notwithstanding chapter 427, the agency is authorized to
 2615  continue contracting for Medicaid nonemergency transportation
 2616  services in agency service area 11 with managed care plans that
 2617  were under contract for those services before July 1, 2004.
 2618         (d) Transportation to access covered services provided by a
 2619  qualified plan pursuant to part IV of this chapter shall be
 2620  contracted for by the plan. A qualified plan is not required to
 2621  purchase such services through a coordinated transportation
 2622  system established pursuant to part I of chapter 427.
 2623         (19) COUNTY HEALTH DEPARTMENTS.County health department
 2624  services shall be reimbursed a rate per visit based on total
 2625  reasonable costs of the clinic, as determined by the agency in
 2626  accordance with federal regulations under the authority of 42
 2627  C.F.R. s. 431.615.
 2628         (20) DIALYSIS.A renal dialysis facility that provides
 2629  dialysis services under s. 409.906(9) must be reimbursed the
 2630  lesser of the amount billed by the provider, the provider’s
 2631  usual and customary charge, or the maximum allowable fee
 2632  established by the agency, whichever amount is less.
 2633         (21) SCHOOL-BASED SERVICES.The agency shall reimburse
 2634  school districts that which certify the state match pursuant to
 2635  ss. 409.9071 and 1011.70 for the federal portion of the school
 2636  district’s allowable costs to deliver the services, based on the
 2637  reimbursement schedule. The school district shall determine the
 2638  costs for delivering services as authorized in ss. 409.9071 and
 2639  1011.70 for which the state match will be certified.
 2640  Reimbursement of school-based providers is contingent on such
 2641  providers being enrolled as Medicaid providers and meeting the
 2642  qualifications contained in 42 C.F.R. s. 440.110, unless
 2643  otherwise waived by the federal Centers for Medicare and
 2644  Medicaid Services Health Care Financing Administration. Speech
 2645  therapy providers who are certified through the Department of
 2646  Education pursuant to rule 6A-4.0176, Florida Administrative
 2647  Code, are eligible for reimbursement for services that are
 2648  provided on school premises. Any employee of the school district
 2649  who has been fingerprinted and has received a criminal
 2650  background check in accordance with Department of Education
 2651  rules and guidelines is shall be exempt from any agency
 2652  requirements relating to criminal background checks.
 2653         (22) The agency shall request and implement Medicaid
 2654  waivers from the federal Health Care Financing Administration to
 2655  advance and treat a portion of the Medicaid nursing home per
 2656  diem as capital for creating and operating a risk-retention
 2657  group for self-insurance purposes, consistent with federal and
 2658  state laws and rules.
 2659         (22)(23)(a)LIMITATION ON REIMBURSEMENT RATES.The agency
 2660  shall establish rates at a level that ensures no increase in
 2661  statewide expenditures resulting from a change in unit costs for
 2662  2 fiscal years effective July 1, 2009. Reimbursement rates for
 2663  the 2 fiscal years shall be as provided in the General
 2664  Appropriations Act.
 2665         (a)(b) This subsection applies to the following provider
 2666  types:
 2667         1. Inpatient hospitals.
 2668         2. Outpatient hospitals.
 2669         3. Nursing homes.
 2670         4. County health departments.
 2671         5. Community intermediate care facilities for the
 2672  developmentally disabled.
 2673         6. Prepaid health plans.
 2674         (b) The agency shall apply the effect of this subsection to
 2675  the reimbursement rates for nursing home diversion programs.
 2676         (c) The agency shall create a workgroup on hospital
 2677  reimbursement, a workgroup on nursing facility reimbursement,
 2678  and a workgroup on managed care plan payment. The workgroups
 2679  shall evaluate alternative reimbursement and payment
 2680  methodologies for hospitals, nursing facilities, and managed
 2681  care plans, including prospective payment methodologies for
 2682  hospitals and nursing facilities. The nursing facility workgroup
 2683  shall also consider price-based methodologies for indirect care
 2684  and acuity adjustments for direct care. The agency shall submit
 2685  a report on the evaluated alternative reimbursement
 2686  methodologies to the relevant committees of the Senate and the
 2687  House of Representatives by November 1, 2009.
 2688         (c)(d) This subsection expires June 30, 2011.
 2689         (23) PAYMENT METHODOLOGIES.If a provider is reimbursed
 2690  based on cost reporting and submits a cost report late and that
 2691  cost report would have been used to set a lower reimbursement
 2692  rate for a rate semester, the provider’s rate for that semester
 2693  shall be retroactively calculated using the new cost report, and
 2694  full payment at the recalculated rate shall be applied
 2695  retroactively. Medicare-granted extensions for filing cost
 2696  reports, if applicable, also apply to Medicaid cost reports.
 2697         (24) RETURN OF PAYMENTS.If a provider fails to notify the
 2698  agency within 5 business days after suspension or disenrollment
 2699  from Medicare, sanctions may be imposed pursuant to this
 2700  chapter, and the provider may be required to return funds paid
 2701  to the provider during the period of time that the provider was
 2702  suspended or disenrolled as a Medicare provider.
 2703         Section 28. Subsection (1) of section 409.9081, Florida
 2704  Statutes, is amended to read:
 2705         409.9081 Copayments.—
 2706         (1) The agency shall require, Subject to federal
 2707  regulations and limitations, each Medicaid recipient must to pay
 2708  at the time of service a nominal copayment for the following
 2709  Medicaid services:
 2710         (a) Hospital outpatient services: up to $3 for each
 2711  hospital outpatient visit.
 2712         (b) Physician services: up to $2 copayment for each visit
 2713  with a primary care physician and up to $3 copayment for each
 2714  visit with a specialty care physician licensed under chapter
 2715  458, chapter 459, chapter 460, chapter 461, or chapter 463.
 2716         (c) Hospital emergency department visits for nonemergency
 2717  care: 5 percent of up to the first $300 of the Medicaid payment
 2718  for emergency room services, not to exceed $15. The agency shall
 2719  seek a federal waiver of the requirement that cost-sharing
 2720  amounts for nonemergency services and care furnished in a
 2721  hospital emergency department be nominal. Upon waiver approval,
 2722  a Medicaid recipient who requests such services and care, must
 2723  pay a $100 copayment to the hospital for the nonemergency
 2724  services and care provided in the hospital emergency department.
 2725         (d) Prescription drugs: a coinsurance equal to 2.5 percent
 2726  of the Medicaid cost of the prescription drug at the time of
 2727  purchase. The maximum coinsurance is shall be $7.50 per
 2728  prescription drug purchased.
 2729         Section 29. Paragraphs (b) and (d) of subsection (4) and
 2730  subsections (8), (34), (44), (47), and (53) of section 409.912,
 2731  Florida Statutes, are amended, and subsections (48) through (52)
 2732  of that section are renumbered as subsections (47) through (51)
 2733  respectively, to read:
 2734         409.912 Cost-effective purchasing of health care.—The
 2735  agency shall purchase goods and services for Medicaid recipients
 2736  in the most cost-effective manner consistent with the delivery
 2737  of quality medical care. To ensure that medical services are
 2738  effectively utilized, the agency may, in any case, require a
 2739  confirmation or second physician’s opinion of the correct
 2740  diagnosis for purposes of authorizing future services under the
 2741  Medicaid program. This section does not restrict access to
 2742  emergency services or poststabilization care services as defined
 2743  in 42 C.F.R. part 438.114. Such confirmation or second opinion
 2744  shall be rendered in a manner approved by the agency. The agency
 2745  shall maximize the use of prepaid per capita and prepaid
 2746  aggregate fixed-sum basis services when appropriate and other
 2747  alternative service delivery and reimbursement methodologies,
 2748  including competitive bidding pursuant to s. 287.057, designed
 2749  to facilitate the cost-effective purchase of a case-managed
 2750  continuum of care. The agency shall also require providers to
 2751  minimize the exposure of recipients to the need for acute
 2752  inpatient, custodial, and other institutional care and the
 2753  inappropriate or unnecessary use of high-cost services. The
 2754  agency shall contract with a vendor to monitor and evaluate the
 2755  clinical practice patterns of providers in order to identify
 2756  trends that are outside the normal practice patterns of a
 2757  provider’s professional peers or the national guidelines of a
 2758  provider’s professional association. The vendor must be able to
 2759  provide information and counseling to a provider whose practice
 2760  patterns are outside the norms, in consultation with the agency,
 2761  to improve patient care and reduce inappropriate utilization.
 2762  The agency may mandate prior authorization, drug therapy
 2763  management, or disease management participation for certain
 2764  populations of Medicaid beneficiaries, certain drug classes, or
 2765  particular drugs to prevent fraud, abuse, overuse, and possible
 2766  dangerous drug interactions. The Pharmaceutical and Therapeutics
 2767  Committee shall make recommendations to the agency on drugs for
 2768  which prior authorization is required. The agency shall inform
 2769  the Pharmaceutical and Therapeutics Committee of its decisions
 2770  regarding drugs subject to prior authorization. The agency is
 2771  authorized to limit the entities it contracts with or enrolls as
 2772  Medicaid providers by developing a provider network through
 2773  provider credentialing. The agency may competitively bid single
 2774  source-provider contracts if procurement of goods or services
 2775  results in demonstrated cost savings to the state without
 2776  limiting access to care. The agency may limit its network based
 2777  on the assessment of beneficiary access to care, provider
 2778  availability, provider quality standards, time and distance
 2779  standards for access to care, the cultural competence of the
 2780  provider network, demographic characteristics of Medicaid
 2781  beneficiaries, practice and provider-to-beneficiary standards,
 2782  appointment wait times, beneficiary use of services, provider
 2783  turnover, provider profiling, provider licensure history,
 2784  previous program integrity investigations and findings, peer
 2785  review, provider Medicaid policy and billing compliance records,
 2786  clinical and medical record audits, and other factors. Providers
 2787  shall not be entitled to enrollment in the Medicaid provider
 2788  network. The agency shall determine instances in which allowing
 2789  Medicaid beneficiaries to purchase durable medical equipment and
 2790  other goods is less expensive to the Medicaid program than long
 2791  term rental of the equipment or goods. The agency may establish
 2792  rules to facilitate purchases in lieu of long-term rentals in
 2793  order to protect against fraud and abuse in the Medicaid program
 2794  as defined in s. 409.913. The agency may seek federal waivers
 2795  necessary to administer these policies.
 2796         (4) The agency may contract with:
 2797         (b) An entity that is providing comprehensive behavioral
 2798  health care services to certain Medicaid recipients through a
 2799  capitated, prepaid arrangement pursuant to the federal waiver
 2800  authorized under s. 409.905(5)(b) provided for by s. 409.905(5).
 2801  Such entity must be licensed under chapter 624, chapter 636, or
 2802  chapter 641, or authorized under paragraph (c) or paragraph (d),
 2803  and must possess the clinical systems and operational competence
 2804  to manage risk and provide comprehensive behavioral health care
 2805  to Medicaid recipients. As used in this paragraph, the term
 2806  “comprehensive behavioral health care services” means covered
 2807  mental health and substance abuse treatment services that are
 2808  available to Medicaid recipients. The Secretary of the
 2809  Department of Children and Family Services must shall approve
 2810  provisions of procurements related to children in the
 2811  department’s care or custody before enrolling such children in a
 2812  prepaid behavioral health plan. Any contract awarded under this
 2813  paragraph must be competitively procured. In developing The
 2814  behavioral health care prepaid plan procurement document must
 2815  require, the agency shall ensure that the procurement document
 2816  requires the contractor to develop and implement a plan to
 2817  ensure compliance with s. 394.4574 related to services provided
 2818  to residents of licensed assisted living facilities that hold a
 2819  limited mental health license. Except as provided in
 2820  subparagraph 5. 8., and except in counties where the Medicaid
 2821  managed care pilot program is authorized pursuant to s. 409.986
 2822  409.91211, the agency shall seek federal approval to contract
 2823  with a single entity meeting these requirements to provide
 2824  comprehensive behavioral health care services to all Medicaid
 2825  recipients not enrolled in a Medicaid managed care plan
 2826  authorized under s. 409.986 409.91211, a provider service
 2827  network authorized under paragraph (d), or a Medicaid health
 2828  maintenance organization in an AHCA area. In an AHCA area where
 2829  the Medicaid managed care pilot program is authorized pursuant
 2830  to s. 409.986 409.91211 in one or more counties, the agency may
 2831  procure a contract with a single entity to serve the remaining
 2832  counties as an AHCA area or the remaining counties may be
 2833  included with an adjacent AHCA area and are subject to this
 2834  paragraph. Each entity must offer a sufficient choice of
 2835  providers in its network to ensure recipient access to care and
 2836  the opportunity to select a provider with whom they are
 2837  satisfied. The network shall include all public mental health
 2838  hospitals. To ensure unimpaired access to behavioral health care
 2839  services by Medicaid recipients, all contracts issued pursuant
 2840  to this paragraph must require that 90 80 percent of the
 2841  capitation paid to the managed care plan, including health
 2842  maintenance organizations and capitated provider service
 2843  networks, to be expended for the provision of behavioral health
 2844  care services. If the managed care plan expends less than 90 80
 2845  percent of the capitation paid for the provision of behavioral
 2846  health care services, the difference shall be returned to the
 2847  agency. The agency shall provide the plan with a certification
 2848  letter indicating the amount of capitation paid during each
 2849  calendar year for behavioral health care services pursuant to
 2850  this section. The agency may reimburse for substance abuse
 2851  treatment services on a fee-for-service basis until the agency
 2852  finds that adequate funds are available for capitated, prepaid
 2853  arrangements.
 2854         1. By January 1, 2001, The agency shall modify the
 2855  contracts with the entities providing comprehensive inpatient
 2856  and outpatient mental health care services to Medicaid
 2857  recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
 2858  Counties, to include substance abuse treatment services.
 2859         2. By July 1, 2003, the agency and the Department of
 2860  Children and Family Services shall execute a written agreement
 2861  that requires collaboration and joint development of all policy,
 2862  budgets, procurement documents, contracts, and monitoring plans
 2863  that have an impact on the state and Medicaid community mental
 2864  health and targeted case management programs.
 2865         2.3. Except as provided in subparagraph 5. 8., by July 1,
 2866  2006, the agency and the Department of Children and Family
 2867  Services shall contract with managed care entities in each AHCA
 2868  area except area 6 or arrange to provide comprehensive inpatient
 2869  and outpatient mental health and substance abuse services
 2870  through capitated prepaid arrangements to all Medicaid
 2871  recipients who are eligible to participate in such plans under
 2872  federal law and regulation. In AHCA areas where there are fewer
 2873  than 150,000 eligible individuals number less than 150,000, the
 2874  agency shall contract with a single managed care plan to provide
 2875  comprehensive behavioral health services to all recipients who
 2876  are not enrolled in a Medicaid health maintenance organization,
 2877  a provider service network authorized under paragraph (d), or a
 2878  Medicaid capitated managed care plan authorized under s. 409.986
 2879  409.91211. The agency may contract with more than one
 2880  comprehensive behavioral health provider to provide care to
 2881  recipients who are not enrolled in a Medicaid capitated managed
 2882  care plan authorized under s. 409.986 409.91211, a provider
 2883  service network authorized under paragraph (d), or a Medicaid
 2884  health maintenance organization in AHCA areas where the eligible
 2885  population exceeds 150,000. In an AHCA area where the Medicaid
 2886  managed care pilot program is authorized pursuant to s. 409.986
 2887  409.91211 in one or more counties, the agency may procure a
 2888  contract with a single entity to serve the remaining counties as
 2889  an AHCA area or the remaining counties may be included with an
 2890  adjacent AHCA area and shall be subject to this paragraph.
 2891  Contracts for comprehensive behavioral health providers awarded
 2892  pursuant to this section must shall be competitively procured.
 2893  Both for-profit and not-for-profit corporations are eligible to
 2894  compete. Managed care plans contracting with the agency under
 2895  subsection (3) or paragraph (d), shall provide and receive
 2896  payment for the same comprehensive behavioral health benefits as
 2897  provided in AHCA rules, including handbooks incorporated by
 2898  reference. In AHCA area 11, the agency shall contract with at
 2899  least two comprehensive behavioral health care providers to
 2900  provide behavioral health care to recipients in that area who
 2901  are enrolled in, or assigned to, the MediPass program. One of
 2902  the behavioral health care contracts must be with the existing
 2903  provider service network pilot project, as described in
 2904  paragraph (d), for the purpose of demonstrating the cost
 2905  effectiveness of the provision of quality mental health services
 2906  through a public hospital-operated managed care model. Payment
 2907  shall be at an agreed-upon capitated rate to ensure cost
 2908  savings. Of the recipients in area 11 who are assigned to
 2909  MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
 2910  MediPass-enrolled recipients shall be assigned to the existing
 2911  provider service network in area 11 for their behavioral care.
 2912         4. By October 1, 2003, the agency and the department shall
 2913  submit a plan to the Governor, the President of the Senate, and
 2914  the Speaker of the House of Representatives which provides for
 2915  the full implementation of capitated prepaid behavioral health
 2916  care in all areas of the state.
 2917         a. Implementation shall begin in 2003 in those AHCA areas
 2918  of the state where the agency is able to establish sufficient
 2919  capitation rates.
 2920         b. If the agency determines that the proposed capitation
 2921  rate in any area is insufficient to provide appropriate
 2922  services, the agency may adjust the capitation rate to ensure
 2923  that care will be available. The agency and the department may
 2924  use existing general revenue to address any additional required
 2925  match but may not over-obligate existing funds on an annualized
 2926  basis.
 2927         c. Subject to any limitations provided in the General
 2928  Appropriations Act, the agency, in compliance with appropriate
 2929  federal authorization, shall develop policies and procedures
 2930  that allow for certification of local and state funds.
 2931         3.5. Children residing in a statewide inpatient psychiatric
 2932  program, or in a Department of Juvenile Justice or a Department
 2933  of Children and Family Services residential program approved as
 2934  a Medicaid behavioral health overlay services provider may not
 2935  be included in a behavioral health care prepaid health plan or
 2936  any other Medicaid managed care plan pursuant to this paragraph.
 2937         6. In converting to a prepaid system of delivery, the
 2938  agency shall in its procurement document require an entity
 2939  providing only comprehensive behavioral health care services to
 2940  prevent the displacement of indigent care patients by enrollees
 2941  in the Medicaid prepaid health plan providing behavioral health
 2942  care services from facilities receiving state funding to provide
 2943  indigent behavioral health care, to facilities licensed under
 2944  chapter 395 which do not receive state funding for indigent
 2945  behavioral health care, or reimburse the unsubsidized facility
 2946  for the cost of behavioral health care provided to the displaced
 2947  indigent care patient.
 2948         4.7. Traditional community mental health providers under
 2949  contract with the Department of Children and Family Services
 2950  pursuant to part IV of chapter 394, child welfare providers
 2951  under contract with the Department of Children and Family
 2952  Services in areas 1 and 6, and inpatient mental health providers
 2953  licensed pursuant to chapter 395 must be offered an opportunity
 2954  to accept or decline a contract to participate in any provider
 2955  network for prepaid behavioral health services.
 2956         5.8. All Medicaid-eligible children, except children in
 2957  area 1 and children in Highlands County, Hardee County, Polk
 2958  County, or Manatee County in of area 6, whose cases that are
 2959  open for child welfare services in the statewide automated child
 2960  welfare information HomeSafeNet system, shall receive their
 2961  behavioral health care services through a specialty prepaid plan
 2962  operated by community-based lead agencies through a single
 2963  agency or formal agreements among several agencies. The
 2964  specialty prepaid plan must result in savings to the state
 2965  comparable to savings achieved in other Medicaid managed care
 2966  and prepaid programs. Such plan must provide mechanisms to
 2967  maximize state and local revenues. The specialty prepaid plan
 2968  shall be developed by the agency and the Department of Children
 2969  and Family Services. The agency may seek federal waivers to
 2970  implement this initiative. Medicaid-eligible children whose
 2971  cases are open for child welfare services in the statewide
 2972  automated child welfare information HomeSafeNet system and who
 2973  reside in AHCA area 10 shall be enrolled in a capitated managed
 2974  care plan, which includes provider service networks, which, in
 2975  coordination with available community-based care providers
 2976  specified in s. 409.1671, shall provide sufficient medical,
 2977  developmental, behavioral, and emotional services to meet the
 2978  needs of these children, subject to funding as provided in the
 2979  General Appropriations Act are exempt from the specialty prepaid
 2980  plan upon the development of a service delivery mechanism for
 2981  children who reside in area 10 as specified in s.
 2982  409.91211(3)(dd).
 2983         (d) A provider service network, which may be reimbursed on
 2984  a fee-for-service or prepaid basis.
 2985         1. A provider service network that which is reimbursed by
 2986  the agency on a prepaid basis is shall be exempt from parts I
 2987  and III of chapter 641, but must comply with the solvency
 2988  requirements in s. 641.2261(2) and meet appropriate financial
 2989  reserve, quality assurance, and patient rights requirements as
 2990  established by the agency.
 2991         2.Medicaid recipients assigned to a provider service
 2992  network shall be chosen equally from those who would otherwise
 2993  have been assigned to prepaid plans and MediPass. The agency may
 2994  is authorized to seek federal Medicaid waivers as necessary to
 2995  implement the provisions of this section. Any contract
 2996  previously awarded to a provider service network operated by a
 2997  hospital pursuant to this subsection shall remain in effect for
 2998  a period of 3 years following the current contract expiration
 2999  date, regardless of any contractual provisions to the contrary.
 3000         3. A provider service network is a network established or
 3001  organized and operated by a health care provider, or group of
 3002  affiliated health care providers, including minority physician
 3003  networks and emergency room diversion programs that meet the
 3004  requirements of s. 409.986 409.91211, which provides a
 3005  substantial proportion of the health care items and services
 3006  under a contract directly through the provider or affiliated
 3007  group of providers and may make arrangements with physicians or
 3008  other health care professionals, health care institutions, or
 3009  any combination of such individuals or institutions to assume
 3010  all or part of the financial risk on a prospective basis for the
 3011  provision of basic health services by the physicians, by other
 3012  health professionals, or through the institutions. The health
 3013  care providers must have a controlling interest in the governing
 3014  body of the provider service network organization.
 3015         (8)(a) The agency may contract on a prepaid or fixed-sum
 3016  basis with an exclusive provider organization to provide health
 3017  care services to Medicaid recipients if provided that the
 3018  exclusive provider organization meets applicable managed care
 3019  plan requirements in this section, ss. 409.987, 409.988
 3020  409.9122, 409.9123, 409.9128, and 627.6472, and other applicable
 3021  provisions of law.
 3022         (b) For a period of no longer than 24 months after the
 3023  effective date of this paragraph, when a member of an exclusive
 3024  provider organization that is contracted by the agency to
 3025  provide health care services to Medicaid recipients in rural
 3026  areas without a health maintenance organization obtains services
 3027  from a provider that participates in the Medicaid program in
 3028  this state, the provider shall be paid in accordance with the
 3029  appropriate fee schedule for services provided to eligible
 3030  Medicaid recipients. The agency may seek waiver authority to
 3031  implement this paragraph.
 3032         (34) The agency and entities that contract with the agency
 3033  to provide health care services to Medicaid recipients under
 3034  this section or ss. 409.986 and 409.987 409.91211 and 409.9122
 3035  must comply with the provisions of s. 641.513 in providing
 3036  emergency services and care to Medicaid recipients and MediPass
 3037  recipients. Where feasible, safe, and cost-effective, the agency
 3038  shall encourage hospitals, emergency medical services providers,
 3039  and other public and private health care providers to work
 3040  together in their local communities to enter into agreements or
 3041  arrangements to ensure access to alternatives to emergency
 3042  services and care for those Medicaid recipients who need
 3043  nonemergent care. The agency shall coordinate with hospitals,
 3044  emergency medical services providers, private health plans,
 3045  capitated managed care networks as established in s. 409.986
 3046  409.91211, and other public and private health care providers to
 3047  implement the provisions of ss. 395.1041(7), 409.91255(3)(g),
 3048  627.6405, and 641.31097 to develop and implement emergency
 3049  department diversion programs for Medicaid recipients.
 3050         (44) The agency for Health Care Administration shall ensure
 3051  that any Medicaid managed care plan as defined in s.
 3052  409.987(2)(f) 409.9122(2)(f), whether paid on a capitated basis
 3053  or a shared savings basis, is cost-effective. For purposes of
 3054  this subsection, the term “cost-effective” means that a
 3055  network’s per-member, per-month costs to the state, including,
 3056  but not limited to, fee-for-service costs, administrative costs,
 3057  and case-management fees, if any, must be no greater than the
 3058  state’s costs associated with contracts for Medicaid services
 3059  established under subsection (3), which may be adjusted for
 3060  health status. The agency shall conduct actuarially sound
 3061  adjustments for health status in order to ensure such cost
 3062  effectiveness and shall annually publish the results on its
 3063  Internet website. Contracts established pursuant to this
 3064  subsection which are not cost-effective may not be renewed.
 3065         (47) The agency shall conduct a study of available
 3066  electronic systems for the purpose of verifying the identity and
 3067  eligibility of a Medicaid recipient. The agency shall recommend
 3068  to the Legislature a plan to implement an electronic
 3069  verification system for Medicaid recipients by January 31, 2005.
 3070         (53) Before seeking an amendment to the state plan for
 3071  purposes of implementing programs authorized by the Deficit
 3072  Reduction Act of 2005, the agency shall notify the Legislature.
 3073         Section 30. Paragraph (a) of subsection (1) of section
 3074  409.915, Florida Statutes, is amended to read:
 3075         409.915 County contributions to Medicaid.—Although the
 3076  state is responsible for the full portion of the state share of
 3077  the matching funds required for the Medicaid program, in order
 3078  to acquire a certain portion of these funds, the state shall
 3079  charge the counties for certain items of care and service as
 3080  provided in this section.
 3081         (1) Each county shall participate in the following items of
 3082  care and service:
 3083         (a) For both health maintenance members and fee-for-service
 3084  beneficiaries, payments for inpatient hospitalization in excess
 3085  of 10 days, but not in excess of 45 days, with the exception of
 3086  pregnant women and children whose income is greater than in
 3087  excess of the federal poverty level and who do not receive a
 3088  Medicaid nonpoverty medical subsidy participate in the Medicaid
 3089  medically needy Program, and for adult lung transplant services.
 3090         Section 31. Section 409.9301, Florida Statutes, is
 3091  transferred, renumbered as section 409.9067, Florida Statutes,
 3092  and subsections (1) and (2) of that section are amended, to
 3093  read:
 3094         409.9067 409.9301 Pharmaceutical expense assistance.—
 3095         (1) PROGRAM ESTABLISHED.—A program is established in the
 3096  agency for Health Care Administration to provide pharmaceutical
 3097  expense assistance to individuals diagnosed with cancer or
 3098  individuals who have obtained received organ transplants who
 3099  received a Medicaid nonpoverty medical subsidy before were
 3100  medically needy recipients prior to January 1, 2006.
 3101         (2) ELIGIBILITY.—Eligibility for the program is limited to
 3102  an individual who:
 3103         (a) Is a resident of this state;
 3104         (b) Was a Medicaid recipient who received a nonpoverty
 3105  medical subsidy before under the Florida Medicaid medically
 3106  needy program prior to January 1, 2006;
 3107         (c) Is eligible for Medicare;
 3108         (d) Is a cancer patient or an organ transplant recipient;
 3109  and
 3110         (e) Requests to be enrolled in the program.
 3111         Section 32. Subsection (1) of section 409.9126, Florida
 3112  Statutes, is amended to read:
 3113         409.9126 Children with special health care needs.—
 3114         (1) Except as provided in subsection (4), children eligible
 3115  for Children’s Medical Services who receive Medicaid benefits,
 3116  and other Medicaid-eligible children with special health care
 3117  needs, are shall be exempt from the provisions of s. 409.987
 3118  409.9122 and shall be served through the Children’s Medical
 3119  Services network established in chapter 391.
 3120         Section 33. The Division of Statutory Revision is requested
 3121  to create part IV of chapter 409, Florida Statutes, consisting
 3122  of sections 409.961-409.978, Florida Statutes, entitled
 3123  “MEDICAID MANAGED CARE.”
 3124         Section 34. Section 409.961, Florida Statutes, is created
 3125  to read:
 3126         409.961Construction; applicability.—It is the intent of
 3127  the Legislature that if any conflict exists between ss. 409.961
 3128  409.978 and other parts or sections of this chapter, the
 3129  provisions in ss. 409.961-409.978 control. Sections 409.961
 3130  409.978 apply only to the Medicaid managed care program, as
 3131  provided in this part.
 3132         Section 35. Section 409.962, Florida Statutes, is created
 3133  to read:
 3134         409.962Definitions.—As used in this part, and including
 3135  the terms defined in s. 409.901, the term:
 3136         (1) “Direct care management” means care management
 3137  activities that involve direct interaction between providers and
 3138  patients.
 3139         (2) “Home and community-based services” means a specific
 3140  set of services designed to assist recipients qualifying under
 3141  s. 409.974 in avoiding institutionalization.
 3142         (3) “Medicaid managed care program” means the integrated,
 3143  statewide Medicaid program created in this part, which includes
 3144  the provision of managed care medical assistance services
 3145  described in ss. 409.971 and 409.972 and managed long-term care
 3146  services described in ss. 409.973-409.978.
 3147         (4)“Provider service network” means an entity of which a
 3148  controlling interest is owned by, or a controlling interest in
 3149  the governing body of the entity is composed of, a health care
 3150  provider, a group of affiliated providers, or a public agency or
 3151  entity that delivers health services. For purposes of this
 3152  chapter, health care providers include Florida-licensed health
 3153  care professionals, Florida-licensed health care facilities,
 3154  federally qualified health centers, and home health care
 3155  agencies.
 3156         (5) “Qualified plan” means a managed care plan that is
 3157  determined eligible to participate in the Medicaid managed care
 3158  program pursuant to s. 409.965.
 3159         (6) “Specialty plan” means a qualified plan that serves
 3160  Medicaid recipients who meet specified criteria based on age,
 3161  medical condition, or diagnosis.
 3162         Section 36. Section 409.963, Florida Statutes, is created
 3163  to read:
 3164         409.963Medicaid managed care program.—The Medicaid managed
 3165  care program is established as a statewide, integrated managed
 3166  care program for all covered medical assistance services and
 3167  long-term care services as provided under this part. Pursuant to
 3168  s. 409.902, the program shall be administered by the agency, and
 3169  eligibility for the program shall be determined by the
 3170  Department of Children and Family Services.
 3171         (1) The agency shall submit amendments to the Medicaid
 3172  state plan or to existing waivers, or submit new waiver requests
 3173  under section 1115 or other applicable sections of the Social
 3174  Security Act, by August 1, 2011, as needed to implement the
 3175  managed care program. At a minimum, the waiver requests must
 3176  include a waiver that allows home and community-based services
 3177  to be preferred over nursing home services for persons who can
 3178  be safely managed in the home and community, and a waiver that
 3179  requires dually eligible recipients to participate in the
 3180  Medicaid managed care program. The waiver requests must also
 3181  include provisions authorizing the state to limit enrollment in
 3182  managed long-term care, establish waiting lists, and limit the
 3183  amount, duration, and scope of home and community-based services
 3184  to ensure that expenditures for persons eligible for managed
 3185  long-term care services do not exceed funds provided in the
 3186  General Appropriations Act.
 3187         (a) The agency shall initiate any necessary procurements
 3188  required to implement the managed care program as soon as
 3189  practicable, but no later than July 1, 2011, in anticipation of
 3190  prompt approval of the waivers needed for the managed care
 3191  program by the United States Department of Health and Human
 3192  Services.
 3193         (b) In submitting waivers, the agency shall work with the
 3194  federal Centers for Medicare and Medicaid Services to accomplish
 3195  approval of all waivers by December 1, 2011, in order to begin
 3196  implementation of the managed care program by December 31, 2011.
 3197         (c) Before seeking a waiver, the agency shall provide
 3198  public notice and the opportunity for public comment and include
 3199  public feedback in the waiver application.
 3200         (2) The agency shall begin implementation of the Medicaid
 3201  managed care program on December 31, 2011. If waiver approval is
 3202  obtained, the program shall be implemented in accordance with
 3203  the terms and conditions of the waiver. If necessary waivers
 3204  have not been timely received, the agency shall notify the
 3205  Centers for Medicare and Medicaid Services of the state’s
 3206  implementation of the managed care program and request the
 3207  federal agency to continue providing federal funds equivalent to
 3208  the funding level provided under the Federal Medical Assistance
 3209  Percentage in order to implement the managed care program.
 3210         (a) If the Centers for Medicare and Medicaid Services
 3211  refuses to continue providing federal funds, the managed care
 3212  program shall be implemented as a state-only funded program to
 3213  the extent state funds are available.
 3214         (b) If implemented as a state-only funded program, priority
 3215  shall be given to providing:
 3216         1. Nursing home services to persons eligible for nursing
 3217  home care.
 3218         2. Medical services to persons served by the Agency for
 3219  Persons with Disabilities.
 3220         3. Medical services to pregnant women.
 3221         4. Physician and hospital services to persons who are
 3222  determined to be eligible for Medicaid subject to the income,
 3223  assets, and categorical eligibility tests set forth in federal
 3224  and state law.
 3225         5. Services provided under the Healthy Start waiver.
 3226         6. Medical services provided to persons in the Nursing Home
 3227  Diversion waiver.
 3228         7. Medical services provided to persons in intermediate
 3229  care facilities for the developmentally disabled.
 3230         8. Services to children in the child welfare system whose
 3231  medical care is provided in accordance with s. 409.16713, as
 3232  authorized by the General Appropriations Act.
 3233         (c)If implemented as a state-only funded program pursuant
 3234  to paragraph (b), provisions related to the eligibility
 3235  standards of the state and federally funded Medicaid program
 3236  remain in effect, except as otherwise provided under the managed
 3237  care program.
 3238         (d) If implemented as a state-only funded program pursuant
 3239  to paragraph (a), provider agreements and other contracts that
 3240  provide for Medicaid services to recipients identified in
 3241  paragraph (b) continue in effect.
 3242         Section 37. Section 409.964, Florida Statutes, is created
 3243  to read:
 3244         409.964Enrollment.—All Medicaid recipients shall receive
 3245  medical services through the Medicaid managed care program
 3246  established under this part unless excluded under this section.
 3247         (1) The following recipients are excluded from
 3248  participation in the Medicaid managed care program:
 3249         (a) Women who are eligible only for family planning
 3250  services.
 3251         (b) Women who are eligible only for breast and cervical
 3252  cancer services.
 3253         (c) Persons who have a developmental disability as defined
 3254  in s. 393.063.
 3255         (d) Persons who are eligible for a Medicaid nonpoverty
 3256  medical subsidy.
 3257         (e) Persons who receive eligible services under emergency
 3258  Medicaid for aliens.
 3259         (f) Persons who are residing in a nursing home facility or
 3260  are considered residents under the nursing home’s bed-hold
 3261  policy on or before July 1, 2011.
 3262         (g) Persons who are eligible for and receiving prescribed
 3263  pediatric extended care.
 3264         (h)Persons who are dependent on a respirator by medical
 3265  necessity and who meet the definition of a medically dependent
 3266  or technologically dependent child under s. 400.902.
 3267         (i) Persons who select the Medicaid hospice benefit and are
 3268  receiving hospice services from a hospice licensed under part IV
 3269  of chapter 400.
 3270         (j)Children residing in a statewide inpatient psychiatric
 3271  program.
 3272         (k)A person who is eligible for services under the
 3273  Medicaid program who has access to health care coverage through
 3274  an employer-sponsored health plan. Such person may not receive
 3275  Medicaid services under the fee-for-service program but may use
 3276  Medicaid financial assistance to pay the cost of premiums for
 3277  the employer-sponsored health plan. For purposes of this
 3278  paragraph, access to health care coverage through an employer
 3279  sponsored health plan means that the Medicaid financial
 3280  assistance available to the person is sufficient to pay the
 3281  premium for the employer-sponsored health plan for the eligible
 3282  person and his or her Medicaid eligible family members.
 3283         1.The agency shall develop a process that allows a
 3284  recipient who has access to employer-sponsored health coverage
 3285  to use Medicaid financial assistance to pay the cost of the
 3286  premium for the recipient and the recipient’s Medicaid-eligible
 3287  family members for such coverage. The amount of financial
 3288  assistance may not exceed the Medicaid capitated rate that would
 3289  have been paid to a qualified plan for that recipient and the
 3290  recipient’s family members.
 3291         2.Contingent upon federal approval, the agency shall also
 3292  allow recipients who have access to other insurance or coverage
 3293  created pursuant to state or federal law to opt out of Medicaid
 3294  managed care and apply the Medicaid capitated rate that would
 3295  have been paid to a qualified plan for that recipient and the
 3296  recipient’s family to pay for the other insurance product.
 3297         (2) The following Medicaid recipients are exempt from
 3298  mandatory enrollment in the managed care program but may
 3299  volunteer to participate in the program:
 3300         (a) Recipients residing in residential commitment
 3301  facilities operated through the Department of Juvenile Justice,
 3302  group care facilities operated by the Department of Children and
 3303  Family Services, or treatment facilities funded through the
 3304  substance abuse and mental health program of the Department of
 3305  Children and Family Services.
 3306         (b) Persons eligible for refugee assistance.
 3307         (3) Medicaid recipients who are exempt from mandatory
 3308  participation under this section and who do not choose to enroll
 3309  in the Medicaid managed care program shall be served though the
 3310  Medicaid fee-for-service program as provided under part III of
 3311  this chapter.
 3312         Section 38. Section 409.965, Florida Statutes, is created
 3313  to read:
 3314         409.965Qualified plans; regions; selection criteria.
 3315  Services in the Medicaid managed care program shall be provided
 3316  by qualified plans.
 3317         (1) The agency shall select qualified plans to participate
 3318  in the Medicaid managed care program using an invitation to
 3319  negotiate issued pursuant to s. 287.057.
 3320         (a) The agency shall notice separate invitations to
 3321  negotiate for the managed medical assistance component and the
 3322  managed long-term care component of the managed care program.
 3323         (b) At least 30 days before noticing the invitation to
 3324  negotiate and annually thereafter, the agency shall compile and
 3325  publish a databook consisting of a comprehensive set of
 3326  utilization and spending data for the 3 most recent contract
 3327  years, consistent with the rate-setting periods for all Medicaid
 3328  recipients by region and county. Pursuant to s. 409.970, the
 3329  source of the data must include both historic fee-for-service
 3330  claims and validated data from the Medicaid Encounter Data
 3331  System. The report shall be made available electronically and
 3332  must delineate utilization by age, gender, eligibility group,
 3333  geographic area, and acuity level.
 3334         (2) Separate and simultaneous procurements shall be
 3335  conducted in each of the following regions:
 3336         (a) Region 1, which consists of Escambia, Okaloosa, Santa
 3337  Rosa, and Walton counties.
 3338         (b) Region 2, which consists of Franklin, Gadsden,
 3339  Jefferson, Leon, Liberty, and Wakulla counties.
 3340         (c) Region 3, which consists of Columbia, Dixie, Hamilton,
 3341  Lafayette, Madison, Suwannee, and Taylor counties.
 3342         (d) Region 4, which consists of Baker, Clay, Duval, and
 3343  Nassau counties.
 3344         (e) Region 5, which consists of Citrus, Hernando, Lake,
 3345  Marion, and Sumter counties.
 3346         (f) Region 6, which consists of Pasco and Pinellas
 3347  counties.
 3348         (g) Region 7, which consists of Flagler, Putnam, St. Johns,
 3349  and Volusia counties.
 3350         (h) Region 8, which consists of Alachua, Bradford,
 3351  Gilchrist, Levy, and Union counties.
 3352         (i) Region 9, which consists of Orange and Osceola
 3353  counties.
 3354         (j) Region 10, which consists of Hardee, Highlands, and
 3355  Polk counties.
 3356         (k) Region 11, which consists of Miami-Dade and Monroe
 3357  counties.
 3358         (l) Region 12, which consists of DeSoto, Manatee, and
 3359  Sarasota counties.
 3360         (m) Region 13, which consists of Hillsborough County.
 3361         (n) Region 14, which consists of Bay, Calhoun, Gulf,
 3362  Holmes, Jackson, and Washington counties.
 3363         (o) Region 15, which consists of Palm Beach County.
 3364         (p) Region 16, which consists of Broward County.
 3365         (q) Region 17, which consists of Brevard and Seminole
 3366  counties.
 3367         (r) Region 18, which consists of Indian River, Martin,
 3368  Okeechobee, and St. Lucie counties.
 3369         (s) Region 19, which consists of Charlotte, Collier,
 3370  Glades, Hendry, and Lee counties.
 3371         (3) The invitation to negotiate must specify the criteria
 3372  and the relative weight of the criteria to be used for
 3373  determining the acceptability of a reply and guiding the
 3374  selection of qualified plans with which the agency shall
 3375  contract. In addition to other criteria developed by the agency,
 3376  the agency shall give preference to the following factors in
 3377  selecting qualified plans:
 3378         (a) Accreditation by the National Committee for Quality
 3379  Assurance or another nationally recognized accrediting body.
 3380         (b) Experience serving similar populations, including the
 3381  organization’s record in achieving specific quality standards
 3382  for similar populations.
 3383         (c) Availability and accessibility of primary care and
 3384  specialty physicians in the provider network.
 3385         (d) Establishment of partnerships with community providers
 3386  that provide community-based services.
 3387         (e) The organization’s commitment to quality improvement
 3388  and documentation of achievements in specific quality
 3389  improvement projects, including active involvement by the
 3390  organization’s leadership.
 3391         (f) Provision of additional benefits, particularly dental
 3392  care for all recipients, disease management, and other programs
 3393  offering additional benefits.
 3394         (g) Establishment of incentive programs that reward
 3395  specific behaviors with health-related benefits not otherwise
 3396  covered by the organizations’ benefit plan. Such behaviors may
 3397  include participation in smoking-cessation programs, weight-loss
 3398  programs, or other activities designed to mitigate lifestyle
 3399  choices and avoid behaviors associated with the use of high-cost
 3400  medical services.
 3401         (h) Organizations without a history of voluntary or
 3402  involuntary withdrawal from any state Medicaid program or
 3403  program area.
 3404         (i) Evidence that an organization has written agreements or
 3405  signed contracts or has made substantial progress in
 3406  establishing relationships with providers before the
 3407  organization submits a reply. The agency shall evaluate such
 3408  evidence based on the following factors:
 3409         1. Contracts with primary care and specialty physicians in
 3410  sufficient numbers to meet the specific performance standards
 3411  established pursuant to s. 409.966(2)(b).
 3412         2. Specific arrangements that provide evidence that the
 3413  compensation offered by the plan is sufficient to retain primary
 3414  care and specialty physicians in sufficient numbers to comply
 3415  with the performance standards established pursuant to s.
 3416  409.966(2) throughout the 5-year contract term. The agency shall
 3417  give preference to plans that provide evidence that primary care
 3418  physicians within the plan’s provider network will be
 3419  compensated for primary care services with payments equivalent
 3420  to or greater than payments for such services under the Medicare
 3421  program, whether compensation is made on a fee-for-service basis
 3422  or by sub-capitation.
 3423         3. Contracts with community pharmacies located in rural
 3424  areas; contracts with community pharmacies serving specialty
 3425  disease populations, including, but not limited to, HIV/AIDS
 3426  patients, hemophiliacs, patients suffering from end-stage renal
 3427  disease, diabetes, or cancer; community pharmacies located
 3428  within distinct cultural communities that reflect the unique
 3429  cultural dynamics of such communities, including, but not
 3430  limited to, languages spoken, ethnicities served, unique disease
 3431  states serviced, and geographic location within the
 3432  neighborhoods of culturally distinct populations; and community
 3433  pharmacies providing value-added services to patients, such as
 3434  free delivery, immunizations, disease management, diabetes
 3435  education, and medication utilization review.
 3436         4. Contracts with cancer disease management programs that
 3437  have a proven record of clinical efficiencies and cost savings.
 3438         5. Contracts with diabetes disease management programs that
 3439  have a proven record of clinical efficiencies and cost savings.
 3440         (j) The capitated rates provided in the reply to the
 3441  invitation to negotiate.
 3442         (k) Establishment of a claims payment process to ensure
 3443  that claims that are not contested or denied will be paid within
 3444  20 days after receipt.
 3445         (l)Utilizing a tiered approach, organizations that are
 3446  based in Florida and have operational functions performed in
 3447  Florida, either performed in-house or through contractual
 3448  arrangements, by Florida-employed staff. The highest number of
 3449  points shall be awarded to any plan with all or substantially
 3450  all of its operational functions performed in the state. The
 3451  second highest number of points shall be awarded to any plan
 3452  with a majority of its operational functions performed in the
 3453  state. The agency may establish a third tier; however, no
 3454  preference points shall be awarded to plans that perform only
 3455  community outreach, medical director functions, and state
 3456  administrative functions in the state. For purposes of this
 3457  paragraph, operational functions include claims processing,
 3458  member services, provider relations, utilization and prior
 3459  authorization, case management, disease and quality functions,
 3460  and finance and administration. For purposes of this paragraph,
 3461  based in Florida means that the entity’s principal office is
 3462  in Florida and the plan is not a subsidiary, directly or
 3463  indirectly through one or more subsidiaries of, or a joint
 3464  venture with, any other entity whose principal office is not
 3465  located in the state.
 3466         (m)For long-term care plans, additional criteria as
 3467  specified in s. 409.976(3).
 3468         (4) Acceptable replies to the invitation to negotiate for
 3469  each region shall be ranked, and the agency shall select the
 3470  number of qualified plans with which to contract in each region.
 3471         (a) The agency may not select more than one plan per 20,000
 3472  Medicaid recipients residing in the region who are subject to
 3473  mandatory managed care enrollment, except that, in addition to
 3474  the Children’s Medical Services Network, a region may not have
 3475  fewer than three or more than 10 qualified plans for the managed
 3476  medical assistance or the managed long-term care components of
 3477  the program.
 3478         (b) If the funding available in the General Appropriations
 3479  Act is not adequate to meet the proposed statewide requirement
 3480  under the Medicaid managed care program, the agency shall enter
 3481  into negotiations with qualified plans that responded to the
 3482  invitation to negotiate. The negotiation process may alter the
 3483  rank of a qualified plan. If negotiations are conducted, the
 3484  agency shall select qualified plans that are responsive and
 3485  provide the best value to the state.
 3486         (5)The agency may issue a new invitation to negotiate in
 3487  any region:
 3488         (a) At any time if:
 3489         1.Data becomes available to the agency indicating that the
 3490  population of recipients residing in the region who are subject
 3491  to mandatory managed care enrollment cannot be served by the
 3492  plans under contract with the agency in that region or has
 3493  increased by more than 20,000 since the most recent invitation
 3494  to negotiate was issued in that region; and
 3495         2.The agency has not contracted with the maximum number of
 3496  plans authorized for that region.
 3497         (b) At any time during the first 2 years after the initial
 3498  contract period and upon the request of a qualified plan under
 3499  contract in one or more regions if:
 3500         1. Data becomes available to the agency indicating that the
 3501  population of Medicaid recipients residing in the region who are
 3502  subject to mandatory managed care enrollment has increased by
 3503  more than 20,000 since the initial invitation to negotiate was
 3504  issued for the contract period; and
 3505         2. The agency has not contracted with the maximum number of
 3506  plans authorized for that region.
 3507  
 3508  The term of a contract executed under this subsection shall be
 3509  for the remainder of the 5-year contract cycle.
 3510         (6) The Children’s Medical Services Network authorized
 3511  under chapter 391 is a qualified plan for purposes of the
 3512  managed care medical assistance component of the Medicaid
 3513  managed care program. Participation by the network shall be
 3514  pursuant to a single statewide contract with the agency which is
 3515  not subject to the procurement requirements of this section. The
 3516  network must meet all other plan requirements for the managed
 3517  care medical assistance component of the program.
 3518         (7) In order to allow a provider service network in rural
 3519  areas sufficient time to develop an adequate provider network to
 3520  participate in the Medicaid managed care program on a capitated
 3521  basis, the network may submit an application or invitation to
 3522  negotiate after July 1, 2011, as required by the agency, for a
 3523  region where there was no Medicaid-contracted health maintenance
 3524  organization or provider service network on July 1, 2011. For
 3525  the first 12 months that the network operates in the region, the
 3526  agency shall assign existing Medicaid provider agreements to the
 3527  provider service network for purposes of administering managed
 3528  care services and building an adequate provider network to meet
 3529  the access standards established by the agency.
 3530         Section 39. Section 409.966, Florida Statutes, is created
 3531  to read:
 3532         409.966Plan contracts.—
 3533         (1) The agency shall execute a 5-year contract with each
 3534  qualified plan selected through the procurement process
 3535  described in s. 409.965. A contract between the agency and the
 3536  qualified plan may be amended annually, or as needed, to reflect
 3537  capitated rate adjustments due to funding availability pursuant
 3538  to the General Appropriations Act and ss. 409.9022, 409.972, and
 3539  409.975(2).
 3540         (a) A plan contract may not be renewed; however, the agency
 3541  may extend the term of a contract, keeping intact all
 3542  operational provisions in the contract, including capitation
 3543  rates, to cover any delays in transitioning to a new plan.
 3544         (b) If a plan applies for a rate increase that is not the
 3545  result of a solicitation from the agency and the application for
 3546  rate increase is not timely withdrawn, the plan will be deemed
 3547  to have submitted a notice of intent to leave the region before
 3548  the end of the contract term.
 3549         (2) The agency shall establish such contract requirements
 3550  as are necessary for the operation of the Medicaid managed care
 3551  program. In addition to any other provisions the agency may deem
 3552  necessary, the contract must require:
 3553         (a) Access.—The agency shall establish specific standards
 3554  for the number, type, and regional distribution of providers in
 3555  plan networks in order to ensure access to care. Each qualified
 3556  plan shall:
 3557         1. Maintain a network of providers in sufficient numbers to
 3558  meet the access standards for specified services for all
 3559  recipients enrolled in the plan.
 3560         2. Establish and maintain an accurate and complete
 3561  electronic database of contracted providers, including
 3562  information about licensure or registration, locations and hours
 3563  of operation, specialty credentials and other certifications,
 3564  specific performance indicators, and such other information as
 3565  the agency deems necessary. The provider database must be
 3566  available online to both the agency and the public and allow
 3567  comparison of the availability of providers to network adequacy
 3568  standards, and accept and display feedback from each provider’s
 3569  patients.
 3570         3. Provide for reasonable and adequate hours of operation,
 3571  including 24-hour availability of information, referral, and
 3572  treatment for emergency medical conditions.
 3573         4. Assign each new enrollee to a primary care provider and
 3574  ensure that an appointment with that provider has been scheduled
 3575  within 30 days after the enrollment in the plan.
 3576         5. Submit quarterly reports to the agency identifying the
 3577  number of enrollees assigned to each primary care provider.
 3578         (b) Performance standards.—The agency shall establish
 3579  specific performance standards and expected milestones or
 3580  timelines for improving plan performance over the term of the
 3581  contract.
 3582         1. Each plan shall establish an internal health care
 3583  quality improvement system that includes enrollee satisfaction
 3584  and disenrollment surveys and incentives and disincentives for
 3585  network providers.
 3586         2. Each plan must collect and report the Health Plan
 3587  Employer Data and Information Set (HEDIS) measures, as specified
 3588  by the agency. These measures must be published on the plan’s
 3589  website in a manner that allows recipients to reliably compare
 3590  the performance of plans. The agency shall use the HEDIS
 3591  measures as a tool to monitor plan performance.
 3592         3. A qualified plan that is not accredited when the
 3593  contract is executed with the agency must become accredited or
 3594  have initiated the accreditation process within 1 year after the
 3595  contract is executed. If the plan is not accredited within 18
 3596  months after executing the contract, the plan shall be suspended
 3597  from automated enrollments pursuant to s. 409.969(2).
 3598         4. In addition to agency standards, a qualified plan must
 3599  ensure that the agency is notified of the impending birth of a
 3600  child to an enrollee or as soon as practicable after the child’s
 3601  birth. Upon the birth, the child is deemed enrolled with the
 3602  qualified plan, regardless of the administrative enrollment
 3603  procedures, and the qualified plan is responsible for providing
 3604  Medicaid services to the child on a capitated basis.
 3605         (c) Program integrity.—Each plan shall establish program
 3606  integrity functions and activities in order to reduce the
 3607  incidence of fraud and abuse, including, at a minimum:
 3608         1. A provider credentialing system and ongoing provider
 3609  monitoring. Each plan must verify at least annually that all
 3610  providers have a valid and unencumbered license or permit to
 3611  provide services to Medicaid recipients, and shall establish a
 3612  procedure for providers to notify the plan when the provider has
 3613  been notified by a licensing or regulatory agency that the
 3614  provider’s license or permit is to be revoked or suspended, or
 3615  when an event has occurred which would prevent the provider from
 3616  renewing its license or permit. The provider must also notify
 3617  the plan if the license or permit is revoked or suspended, if
 3618  renewal of the license or permit is denied or expires by
 3619  operation of law, or if the provider requests that the license
 3620  or permit be inactivated. The plan must immediately exclude a
 3621  provider from the plan’s provider network if the provider’s
 3622  license is suspended or invalid. However, this section does not
 3623  preclude a plan from contracting with a provider that is
 3624  approved via a final order, has commenced construction, and will
 3625  be licensed and operational within 18 months after the effective
 3626  date of this act;
 3627         2. An effective prepayment and postpayment review process
 3628  that includes, at a minimum, data analysis, system editing, and
 3629  auditing of network providers;
 3630         3. Procedures for reporting instances of fraud and abuse
 3631  pursuant to s. 409.91212;
 3632         4. The establishment of an anti-fraud plan pursuant to s.
 3633  409.91212; and
 3634         5. Designation of a program integrity compliance officer.
 3635         (d) Encounter data.—Each plan must comply with the agency’s
 3636  reporting requirements for the Medicaid Encounter Data System
 3637  under s. 409.970. The agency shall assess a fine of $5,000 per
 3638  day against a qualified plan for failing to comply with this
 3639  requirement. If a plan fails to comply for more than 30 days,
 3640  the agency shall assess a fine of $10,000 per day beginning on
 3641  the 31st day. If a plan is fined $300,000 or more for failing to
 3642  comply, in addition to paying the fine, the plan shall be
 3643  disqualified from the Medicaid managed care program for 3 years.
 3644  If the plan is disqualified, the plan shall be deemed to have
 3645  terminated its contract before the scheduled end date and shall
 3646  also be subject to applicable penalties under paragraph (l).
 3647  However, the agency may waive or reduce the fine upon a showing
 3648  of good cause for the failure to comply.
 3649         (e)Electronic claims and prior authorization requests.
 3650  Plans shall accept electronic claims that are in compliance with
 3651  federal standards and accept electronic prior authorization
 3652  requests from prescribers and pharmacists for medication
 3653  exceptions to the preferred drug list or formulary. The criteria
 3654  for the approval and the reasons for denial of prior
 3655  authorization requests shall be made readily available to
 3656  prescribers and pharmacists submitting the request.
 3657         (f) Prompt payment.—All qualified plans must comply with
 3658  ss. 641.315, 641.3155, and 641.513. Qualified plans shall pay
 3659  nursing homes by the 10th day of the month for enrollees who are
 3660  residing in the nursing home on the 1st day of the month.
 3661  Payment for the month in which an enrollee initiates residency
 3662  in a nursing home shall be in accordance with s. 641.3155. On an
 3663  annual basis, qualified plans shall submit a report certifying
 3664  compliance with the prompt payment requirements for the plan
 3665  year.
 3666         (g) Emergency services.—Qualified plans must pay for
 3667  emergency services and care required under ss. 395.1041 and
 3668  401.45 and rendered by a noncontracted provider in accordance
 3669  with the prompt payment standards established in s. 641.3155.
 3670  The payment rate shall be the fee-for-service rate the agency
 3671  would pay the noncontracted provider for such services, unless
 3672  the agency has developed an average rate for the noncontracted
 3673  provider for such services under s. 409.967(3)(c). If the agency
 3674  has developed an average rate for the noncontracted provider for
 3675  such services under s. 409.967(3)(c), the payment rate for such
 3676  services under this paragraph shall be the average rate
 3677  developed by the agency for the noncontracted provider for such
 3678  services under s. 409.967(3)(c).
 3679         (h) Surety bond.—A qualified plan shall post and maintain a
 3680  surety bond with the agency, payable to the agency, or in lieu
 3681  of a surety bond, establish and maintain an irrevocable letter
 3682  of credit or a deposit in a trust account in a financial
 3683  institution, payable to the agency.
 3684         1. The amount of the surety bond, letter of credit, or
 3685  trust account shall be 125 percent of the estimated annual
 3686  guaranteed savings for each qualified plan, and at least $2
 3687  million but no more than $15 million for each qualified plan.
 3688  The estimated guaranteed savings shall be calculated before the
 3689  execution of the contract as follows:
 3690         a. The agreed-upon monthly contractual capitated rate for
 3691  each level of acuity multiplied by the estimated population in
 3692  the region for the plan for each level of acuity, multiplied by
 3693  12 months, multiplied by 7 percent, multiplied by 125 percent.
 3694         b. The estimated population in the region for the plan
 3695  under sub-subparagraph a. shall be based on the maximum enrollee
 3696  level that the agency initially authorizes. The factors that the
 3697  agency may consider in determining the maximum enrollee level
 3698  include, but are not limited to, requested capacity, projected
 3699  enrollment, network adequacy, and the available budget in the
 3700  General Appropriations Act.
 3701         2. The purpose of the surety bond, letter of credit, or
 3702  trust account is to protect the agency if the entity terminates
 3703  its contract with the agency before the scheduled end date for
 3704  the contract, if the plan fails to comply with the terms of the
 3705  contract, including, but not limited to, the timely submission
 3706  of encounter data, if the agency imposes fines or penalties for
 3707  noncompliance, or if the plan fails to achieve the guaranteed
 3708  savings. If any of those events occurs, the agency shall first
 3709  request payment from the qualified plan. If the qualified plan
 3710  does not pay all costs, fines, penalties, or the differential in
 3711  the guaranteed savings in full within 30 days, the agency shall
 3712  pursue a claim against the surety bond, letter of credit, or
 3713  trust account for all applicable moneys and the legal and
 3714  administrative costs associated with pursuing such claim.
 3715         (i) Grievance resolution.—Each plan shall establish and the
 3716  agency shall approve an internal process for reviewing and
 3717  responding to grievances from enrollees consistent with s.
 3718  641.511. Each plan shall submit quarterly reports to the agency
 3719  on the number, description, and outcome of grievances filed by
 3720  enrollees.
 3721         (j) Solvency.—A qualified plan must meet and maintain the
 3722  surplus and solvency requirements under s. 409.912(17) and (18).
 3723  A provider service network may satisfy the surplus and solvency
 3724  requirements if the network’s performance and financial
 3725  obligations are guaranteed in writing by an entity licensed by
 3726  the Office of Insurance Regulation which meets the surplus and
 3727  solvency requirements of s. 624.408 or s. 641.225.
 3728         (k)Guaranteed savings.During the first contract period, a
 3729  qualified plan must agree to provide a guaranteed minimum
 3730  savings of 7 percent to the state. The agency shall conduct a
 3731  cost reconciliation to determine the amount of cost savings
 3732  achieved by the qualified plan compared with the reimbursements
 3733  the agency would have incurred under fee-for-service provisions.
 3734         (l) Costs and penalties.—Plans that reduce enrollment
 3735  levels or leave a region before the end of the contract term
 3736  must reimburse the agency for the cost of enrollment changes and
 3737  other transition activities. If more than one plan leaves a
 3738  region at the same time, costs shall be shared by the departing
 3739  plans proportionate to their enrollment. In addition to the
 3740  payment of costs, departing plans must pay a penalty of 1
 3741  month’s payment calculated as an average of the past 12 months
 3742  of payments, or since inception if the plan has not contracted
 3743  with the agency for 12 months, plus the differential of the
 3744  guaranteed savings based on the original contract term and the
 3745  corresponding termination date. Plans must provide the agency
 3746  with at least 180 days notice before withdrawing from a region.
 3747         (m)Formulary.—Upon recommendation of the Medicaid
 3748  Pharmaceutical and Therapeutics Committee as defined in s.
 3749  409.91195, all qualified plans must adopt a standard minimum
 3750  preferred drug list as described in s. 409.912(39). A plan may
 3751  offer additional products on its formulary. Each plan must
 3752  publish an up-to-date listing of its formulary on a publicly
 3753  available website.
 3754         (3) If the agency terminates more than one regional
 3755  contract with a qualified plan due to the plan’s noncompliance
 3756  with one or more requirements of this section, the agency shall
 3757  terminate all regional contracts with the plan under the
 3758  Medicaid managed care program, as well as any other contracts or
 3759  agreements for other programs or services, and the plan may not
 3760  be awarded new contracts for 3 years.
 3761         Section 40. Section 409.967, Florida Statutes, is created
 3762  to read:
 3763         409.967Plan accountability.—In addition to the contract
 3764  requirements of s. 409.966, plans and providers participating in
 3765  the Medicaid managed care program must comply with this section.
 3766         (1) The agency shall require qualified plans to use a
 3767  uniform method of reporting and accounting for medical, direct
 3768  care management, and nonmedical costs and shall evaluate plan
 3769  spending patterns after the plan completes 2 full years of
 3770  operation and at least annually thereafter.
 3771         (2) The agency shall establish and the qualified plans
 3772  shall use a uniform method for annually reporting premium
 3773  revenue, medical and administrative costs, and income or losses
 3774  across all state Medicaid prepaid plan lines of business in all
 3775  regions. The reports are due to the agency within 270 days after
 3776  the conclusion of the reporting period, and the agency may audit
 3777  the reports. Achieved savings rebates are due within 30 days
 3778  after the report is submitted.
 3779         (a) Except as provided in paragraph (b), the achieved
 3780  savings rebate is established by determining pretax income as a
 3781  percentage of revenues and applying the following income sharing
 3782  ratios:
 3783         1. One hundred percent of income up to and including 5
 3784  percent of revenue shall be retained by the plan.
 3785         2. Fifty percent of income above 5 percent and up to 10
 3786  percent shall be retained by the plan, with the other 50 percent
 3787  refunded to the state.
 3788         3. One hundred percent of income above 10 percent of
 3789  revenue shall be refunded to the state.
 3790         (b) A plan that meets or exceeds agency defined quality
 3791  measures in the reporting period may retain an additional 1
 3792  percent of revenue.
 3793         (c) The following expenses may not be included in
 3794  calculating income to the plan:
 3795         1. Payment of achieved savings rebates.
 3796         2. Any financial incentive payments made to the plan
 3797  outside of the capitation rate.
 3798         3. Any financial disincentive payments levied by the state
 3799  or federal governments.
 3800         4. Expenses associated with lobbying activities.
 3801         5. Administrative, reinsurance, and outstanding claims
 3802  expenses in excess of actuarially sound maximum amounts set by
 3803  the agency.
 3804         (d) Qualified plans that incur a loss in the first contract
 3805  year may apply the full amount of the loss as an offset to
 3806  income in the second contract year.
 3807         (e) If, after an audit or other reconciliation, the agency
 3808  determines that a qualified plan owes an additional rebate, the
 3809  plan has 30 days after notification to make payment. Upon
 3810  failure to timely pay the rebate, the agency shall withhold
 3811  future payments to the plan until the entire amount is recouped.
 3812  If the agency determines that a plan has made an overpayment,
 3813  the agency shall return the overpayment within 30 days.
 3814         (3) Plans may limit the providers in their networks.
 3815         (a) However, during the first year in which a qualified
 3816  plan is operating in a region after the initial plan procurement
 3817  for that region, the plan must offer a network contract to the
 3818  following providers in the region:
 3819         1. Federally qualified health centers.
 3820         2. Nursing homes if the plan is providing managed long-term
 3821  care services.
 3822         3. Aging network service providers that have previously
 3823  participated in home and community-based waivers serving elders,
 3824  or community-service programs administered by the Department of
 3825  Elderly Affairs if the plan is providing managed long-term care
 3826  services.
 3827         (b) After 12 months of active participation in a plan’s
 3828  network, the plan may exclude any of the providers listed in
 3829  paragraph (a) from the network while maintaining the network
 3830  performance standards required under s. 409.966(2)(b). If the
 3831  plan excludes a nursing home that meets the standards for
 3832  ongoing Medicaid certification, the plan must provide an
 3833  alternative residence in that community for Medicaid recipients
 3834  residing in that nursing home. If a Medicaid recipient residing
 3835  in an excluded nursing home does not choose to change residence,
 3836  the plan must continue to pay for the recipient’s care in that
 3837  nursing home. If the plan excludes a provider, the plan must
 3838  provide written notice to all enrollees who have chosen that
 3839  provider for care. Notice to excluded providers must be
 3840  delivered at least 30 days before the effective date of the
 3841  exclusion.
 3842         (c) Notwithstanding the limitation provided in this
 3843  subsection, qualified plans must include the following essential
 3844  providers in their networks:
 3845         1. Faculty plans of state medical schools;
 3846         2. Regional perinatal intensive care centers as defined in
 3847  s. 383.16; and
 3848         3. Hospitals licensed as a children’s specialty hospital as
 3849  defined in s. 395.002.
 3850  
 3851  Qualified plans that have not contracted with all statewide
 3852  essential providers as of the first date of recipient enrollment
 3853  must continue to negotiate in good faith. Payments to physicians
 3854  on the faculty of nonparticipating state medical schools must be
 3855  made at the applicable Medicaid rate. Payments for services
 3856  rendered by a regional perinatal intensive care center must be
 3857  at the applicable Medicaid rate as of the first day of the
 3858  contract between the agency and the plan. Payments to a
 3859  nonparticipating specialty children’s hospital must equal the
 3860  highest rate established by contract between that provider and
 3861  any other Medicaid managed care plan.
 3862         (d) Qualified plans and providers shall engage in good
 3863  faith negotiations to reach contract terms.
 3864         1. If a qualified plan seeks to develop a provider network
 3865  in a county or region that, as of June 30, 2011, does not have a
 3866  capitated managed care plan providing comprehensive acute care
 3867  for Medicaid recipients, and the qualified plan has made at
 3868  least three documented, unsuccessful, good faith attempts to
 3869  contract with a specific provider, the plan may request the
 3870  agency to examine the negotiation process. During the
 3871  examination, the agency shall consider similar counties or
 3872  regions in which qualified plans have contracted with providers
 3873  under similar circumstances, as well as the contracted rates
 3874  between qualified plans and that provider and similar providers
 3875  in the same region. If the agency determines that the plan has
 3876  made three good faith attempts to contract with the provider,
 3877  the agency shall consider that provider to be part of the
 3878  qualified plan’s provider network for the purpose of determining
 3879  network adequacy, and the plan shall pay the provider for
 3880  services to Medicaid recipients on a noncontracted basis at a
 3881  rate or rates determined by the agency to be the average of
 3882  rates for corresponding services paid by the qualified plan and
 3883  other qualified plans in the region and in similar counties or
 3884  regions under similar circumstances.
 3885         2. The agency may continue to calculate Medicaid hospital
 3886  inpatient per diem rates and outpatient rates. However, these
 3887  rates may not be the basis for contract negotiations between a
 3888  managed care plan and a hospital.
 3889         (4) Each qualified plan shall monitor the quality and
 3890  performance of each provider within its network based on metrics
 3891  established by the agency for evaluating and documenting
 3892  provider performance and determining continued participation in
 3893  the network. However, qualified plans are not required to
 3894  conduct surveys of health care facilities that the agency
 3895  surveys periodically for licensure or certification purposes and
 3896  shall accept the results of such surveys. The agency shall
 3897  establish requirements for qualified plans to report, at least
 3898  annually, provider performance data compiled under this
 3899  subsection. If a plan uses additional metrics to evaluate the
 3900  provider’s performance and to determine continued participation
 3901  in the network, the plan must notify the network providers of
 3902  these metrics at the beginning of the contract period.
 3903         (a) At a minimum, a qualified plan shall hold primary care
 3904  physicians responsible for the following activities:
 3905         1. Supervision, coordination, and provision of care to each
 3906  assigned enrollee.
 3907         2. Initiation of referrals for medically necessary
 3908  specialty care and other services.
 3909         3. Maintaining continuity of care for each assigned
 3910  enrollee.
 3911         4. Maintaining the enrollee’s medical record, including
 3912  documentation of all medical services provided to the enrollee
 3913  by the primary care physician, as well as any specialty or
 3914  referral services.
 3915         (b) Qualified plans shall establish and implement policies
 3916  and procedures to monitor primary care physician activities and
 3917  ensure that primary care physicians are adequately notified and
 3918  receive documentation of specialty and referral services
 3919  provided to enrollees by specialty physicians and other health
 3920  care providers within the plan’s provider network.
 3921         (5) Each qualified plan shall establish specific programs
 3922  and procedures to improve pregnancy outcomes and infant health,
 3923  including, but not limited to, coordination with the Healthy
 3924  Start program, immunization programs, and referral to the
 3925  Special Supplemental Nutrition Program for Women, Infants, and
 3926  Children, and the Children’s Medical Services Program for
 3927  children with special health care needs.
 3928         (a) Qualified plans must ensure that primary care
 3929  physicians who provide obstetrical care are available to
 3930  pregnant recipients and that an obstetrical care provider is
 3931  assigned to each pregnant recipient for the duration of her
 3932  pregnancy and postpartum care, by referral of the recipient’s
 3933  primary care physician if necessary.
 3934         (b) Qualified plans within the managed long-term care
 3935  component are exempt from this subsection.
 3936         (6) Each qualified plan shall achieve an annual screening
 3937  rate for early and periodic screening, diagnosis, and treatment
 3938  services of at least 80 percent of those recipients continuously
 3939  enrolled for at least 8 months. Qualified plans within the
 3940  managed long-term care component are exempt from this
 3941  requirement.
 3942         (7) Effective January 1, 2013, qualified plans must
 3943  compensate primary care physicians for primary care services at
 3944  payment rates that are equivalent to or greater than payments
 3945  under the federal Medicare program, whether compensation is made
 3946  on a fee-for-service basis or by sub-capitation.
 3947         (8) In order to protect the continued operation of the
 3948  Medicaid managed care program, unresolved disputes, including
 3949  claim and other types of disputes, between a qualified plan and
 3950  a provider shall proceed in accordance with s. 408.7057. This
 3951  process may not be used to review or reverse a decision by a
 3952  qualified plan to exclude a provider from its network if the
 3953  decision does not conflict with s. 409.967(3).
 3954         Section 41. Section 409.968, Florida Statutes, is created
 3955  to read:
 3956         409.968Plan payment.—Payments for managed medical
 3957  assistance and managed long-term care services under this part
 3958  shall be made in accordance with a capitated managed care model.
 3959  Qualified plans shall receive per-member, per-month payments
 3960  pursuant to the procurements described in s. 409.965 and annual
 3961  adjustments as described in s. 409.966(1). Payment rates must be
 3962  based on the acuity level for each member pursuant to ss.
 3963  409.972 and 409.978. Payment rates for managed long-term care
 3964  plans shall be combined with rates for managed medical
 3965  assistance plans.
 3966         (1) The agency shall develop a methodology and request a
 3967  waiver that ensures the availability of intergovernmental
 3968  transfers and certified public expenditures in the Medicaid
 3969  managed care program to support providers that have historically
 3970  served Medicaid recipients. Such providers include, but are not
 3971  limited to, safety net providers, trauma hospitals, children’s
 3972  hospitals, statutory teaching hospitals, and medical and
 3973  osteopathic physicians employed by or under contract with a
 3974  medical school in this state. The agency may develop a
 3975  supplemental capitation rate, risk pool, or incentive payment
 3976  for plans that contract with these providers. A plan is eligible
 3977  for a supplemental payment only if there are sufficient
 3978  intergovernmental transfers or certified public expenditures
 3979  available from allowable sources.
 3980         (2) The agency shall evaluate the development of the rate
 3981  cell to accurately reflect the underlying utilization to the
 3982  maximum extent possible. This methodology may include interim
 3983  rate adjustments as permitted under federal regulations. Any
 3984  such methodology must preserve federal funding to these entities
 3985  and be actuarially sound. In the absence of federal approval of
 3986  the methodology, the agency may set an enhanced rate and require
 3987  that plans pay the rate if the agency determines the enhanced
 3988  rate is necessary to ensure access to care by the providers
 3989  described in this subsection.
 3990         (3) The amount paid to the plans to make supplemental
 3991  payments or to enhance provider rates pursuant to this
 3992  subsection must be reconciled to the exact amounts the plans are
 3993  required to pay providers. The plans shall make the designated
 3994  payments to providers within 15 business days after notification
 3995  by the agency regarding provider-specific distributions.
 3996         (4) The agency shall develop a methodology and request a
 3997  state plan amendment or waiver that ensures the availability of
 3998  certified public expenditures in the Medicaid managed care
 3999  program to support noninstitutional teaching faculty providers
 4000  that have historically served Medicaid recipients. Such
 4001  providers include allopathic and osteopathic physicians employed
 4002  by or under contract with a medical school in this state. The
 4003  agency shall directly make supplemental payments to teaching
 4004  faculty providers or to a statewide entity acting on behalf of
 4005  state medical schools and teaching faculty providers that
 4006  contract with qualified plans and provide care to Medicaid
 4007  recipients in recognition of the costs associated with graduate
 4008  medical education and training, educating medical school
 4009  students, and access to primary and specialty care provided to
 4010  Medicaid recipients. Physicians employed by or under contract
 4011  with a medical school in this state are eligible for a
 4012  supplemental payment only if there are sufficient certified
 4013  public expenditures available from allowable sources. The agency
 4014  shall evaluate the development of teaching faculty provider
 4015  payments for managed care to accurately reflect the historical
 4016  and underlying as well as current and prospective utilization to
 4017  the maximum extent possible. Any such methodology must preserve
 4018  federal funding to these entities.
 4019         Section 42. Section 409.969, Florida Statutes, is created
 4020  to read:
 4021         409.969Enrollment; disenrollment; grievance procedure.—
 4022         (1) Each Medicaid recipient may choose any available plan
 4023  within the region in which the recipient resides unless that
 4024  plan is a specialty plan for which the recipient does not
 4025  qualify. The agency may not provide or contract for choice
 4026  counseling services for persons enrolling in the Medicaid
 4027  managed care program.
 4028         (2) If a recipient has not made a choice of plans within 30
 4029  days after having been notified to choose a plan, the agency
 4030  shall assign the recipient to a plan in accordance with the
 4031  following:
 4032         (a) A recipient who was previously enrolled in a plan
 4033  within the preceding 90 days shall automatically be enrolled in
 4034  the same plan, if available.
 4035         (b) Newborns of eligible mothers enrolled in a plan at the
 4036  time of the child’s birth shall be enrolled in the mother’s
 4037  plan; however, the mother may choose another plan for the
 4038  newborn within 90 days after the child’s birth.
 4039         (c) If the recipient is diagnosed with HIV/AIDS and resides
 4040  in region 11, region 15, or region 16, the agency shall assign
 4041  the recipient to a plan that:
 4042         1.Is a specialty plan under contract with the agency
 4043  pursuant to s. 409.965; and
 4044         2. Offers a delivery system through a teaching- and
 4045  research-oriented organization that specializes in providing
 4046  health care services and treatment for individuals diagnosed
 4047  with HIV/AIDS.
 4048  
 4049  The agency shall assign recipients under this paragraph on an
 4050  even basis among all such plans within a region under contract
 4051  with the agency.
 4052         (d)A recipient who is currently receiving Medicare
 4053  services from an entity qualified under 42 C.F.R. part 422 as a
 4054  Medicare Advantage preferred provider organization, Medicare
 4055  Advantage provider-sponsored organization, or Medicare Advantage
 4056  special needs plan that is under contract with the agency shall
 4057  be assigned to that plan for the Medicaid services not covered
 4058  by Medicare for which the recipient is eligible.
 4059         (e) Other recipients shall be enrolled into a qualified
 4060  plan in accordance with an auto-assignment enrollment algorithm
 4061  that the agency develops by rule. The algorithm must heavily
 4062  weigh family continuity.
 4063         1. Automatic enrollment of recipients in plans must be
 4064  based on the following criteria:
 4065         a. Whether the plan has sufficient network capacity to meet
 4066  the needs of recipients.
 4067         b. Whether the recipient has previously received services
 4068  from one of the plan’s primary care providers.
 4069         c. Whether primary care providers in one plan are more
 4070  geographically accessible to the recipient’s residence than
 4071  providers in other plans.
 4072         d.If a recipient is eligible for long-term care services,
 4073  whether the recipient has previously received services from one
 4074  of the plan’s home and community-based service providers.
 4075         e.If a recipient is eligible for long-term care services,
 4076  whether the home and community-based providers in one plan are
 4077  more geographically accessible to the recipient’s residence than
 4078  providers in other plans.
 4079         2.The agency shall automatically enroll recipients in
 4080  plans that meet or exceed the performance or quality standards
 4081  established pursuant to s. 409.967, and may not automatically
 4082  enroll recipients in a plan that is not meeting those standards.
 4083  Except as provided by law or rule, the agency may not engage in
 4084  practices that favor one qualified plan over another.
 4085         (3) After a recipient has enrolled in a qualified plan, the
 4086  enrollee shall have 90 days to voluntarily disenroll and select
 4087  another plan. After 90 days, no further changes may be made
 4088  except for good cause. Good cause includes, but is not limited
 4089  to, poor quality of care, lack of access to necessary specialty
 4090  services, an unreasonable delay or denial of service, or
 4091  fraudulent enrollment. The agency shall determine whether good
 4092  cause exists. The agency may require an enrollee to use the
 4093  plan’s grievance process before the agency makes a determination
 4094  of good cause, unless an immediate risk of permanent damage to
 4095  the enrollee’s health is alleged.
 4096         (a) If used, the qualified plan’s internal grievance
 4097  process must be completed in time to allow the enrollee to
 4098  disenroll by the first day of the second month after the month
 4099  the disenrollment request was made. If the grievance process
 4100  approves an enrollee’s request to disenroll, the agency is not
 4101  required to make a determination of good cause.
 4102         (b) The agency must make a determination of good cause and
 4103  take final action on an enrollee’s request so that disenrollment
 4104  occurs by the first day of the second month after the month the
 4105  request was made. If the agency fails to act within this
 4106  timeframe, the enrollee’s request to disenroll is deemed
 4107  approved as of the date agency action was required. Enrollees
 4108  who disagree with the agency’s finding that good cause for
 4109  disenrollment does not exist shall be advised of their right to
 4110  pursue a Medicaid fair hearing to dispute the agency’s finding.
 4111         (c) Medicaid recipients enrolled in a qualified plan after
 4112  the 90-day period must remain in the plan for the remainder of
 4113  the 12-month period. After 12 months, the enrollee may select
 4114  another plan. However, a recipient who is referred for nursing
 4115  home or assisted living facility services may change plans
 4116  within 30 days after such referral. An enrollee may change
 4117  primary care providers within the plan at any time.
 4118         (d) On the first day of the next month after receiving
 4119  notice from a recipient that the recipient has moved to another
 4120  region, the agency shall automatically disenroll the recipient
 4121  from the plan the recipient is currently enrolled in and treat
 4122  the recipient as if the recipient is a new enrollee. At that
 4123  time, the recipient may choose another plan pursuant to the
 4124  enrollment process established in this section.
 4125         Section 43. Section 409.970, Florida Statutes, is created
 4126  to read:
 4127         409.970Medicaid Encounter Data System.—The agency shall
 4128  maintain and operate the Medicaid Encounter Data System to
 4129  collect, process, and report on covered services provided to all
 4130  Medicaid recipients enrolled in qualified plans.
 4131         (1) Qualified plans shall submit encounter data
 4132  electronically in a format that complies with provisions of the
 4133  federal Health Insurance Portability and Accountability Act for
 4134  electronic claims and in accordance with deadlines established
 4135  by the agency. Plans must certify that the data reported is
 4136  accurate and complete. The agency is responsible for validating
 4137  the data submitted by the plans.
 4138         (2) The agency shall develop methods and protocols for
 4139  ongoing analysis of the encounter data, which must adjust for
 4140  differences in the characteristics of enrollees in order to
 4141  allow for the comparison of service utilization among plans. The
 4142  analysis shall be used to identify possible cases of systemic
 4143  overutilization, underutilization, inappropriate denials of
 4144  claims, and inappropriate utilization of covered services, such
 4145  as higher than expected emergency department and pharmacy
 4146  encounters. One of the primary focus areas for the analysis
 4147  shall be the use of prescription drugs.
 4148         (3) The agency shall provide periodic feedback to the plans
 4149  based on the analysis and establish corrective action plans if
 4150  necessary.
 4151         (4) The agency shall make encounter data available to plans
 4152  accepting enrollees who are reassigned to them from other plans
 4153  leaving a region.
 4154         (5) Beginning July 1, 2011, the agency shall conduct
 4155  appropriate tests and establish specific criteria for
 4156  determining whether the Medicaid Encounter Data System has
 4157  valid, complete, and sound data for a sufficient period of time
 4158  to provide qualified plans with a reliable basis for determining
 4159  and proposing actuarially sound payment rates.
 4160         Section 44. Section 409.971, Florida Statutes, is created
 4161  to read:
 4162         409.971Managed care medical assistance.—Pursuant to s.
 4163  409.902, the agency shall administer the managed care medical
 4164  assistance component of the Medicaid managed care program
 4165  described in this section and s. 409.972. Unless otherwise
 4166  specified, the provisions of ss. 409.961-409.970 apply to the
 4167  provision of managed care medical assistance. By December 31,
 4168  2011, the agency shall begin implementation of managed care
 4169  medical assistance, and full implementation in all regions must
 4170  be completed by December 31, 2012.
 4171         Section 45. Section 409.972, Florida Statutes, is created
 4172  to read:
 4173         409.972Managed care medical assistance services.—
 4174         (1) Qualified plans providing managed care medical
 4175  assistance must, at a minimum, cover the following services:
 4176         (a) Ambulatory patient services.
 4177         (b) Dental services for a recipient who is under age 21.
 4178         (c) Dental services as provided in s. 627.419(7) for a
 4179  recipient who is 21 years of age or older.
 4180         (d) Dialysis services.
 4181         (e) Durable medical equipment and supplies.
 4182         (f) Early periodic screening diagnosis and treatment
 4183  services, hearing services and hearing aids, and vision services
 4184  and eyeglasses for enrollees under age 21.
 4185         (g) Emergency services.
 4186         (h) Family planning services.
 4187         (i) Hearing services for a recipient who is under age 21.
 4188         (j) Hearing services that are medically indicated for a
 4189  recipient who is 21 years of age or older.
 4190         (k) Home health services.
 4191         (l) Hospital inpatient services.
 4192         (m) Hospital outpatient services.
 4193         (n) Laboratory and imaging services.
 4194         (o) Maternity and newborn care and birth center services.
 4195         (p) Mental health services, substance abuse disorder
 4196  services, and behavioral health treatment.
 4197         (q) Prescription drugs.
 4198         (r) Primary care service, referred specialty care services,
 4199  preventive services, and wellness services.
 4200         (s) Skilled nursing facility or inpatient rehabilitation
 4201  facility services.
 4202         (t) Transplant services.
 4203         (u) Transportation to access covered services.
 4204         (v) Vision services for a recipient who is under age 21.
 4205         (w)Vision services that are medically indicated for a
 4206  recipient who is 21 years of age or older.
 4207         (2) Subject to specific appropriations, the agency may make
 4208  payments for services that are optional.
 4209         (3) Qualified plans may customize benefit packages for
 4210  nonpregnant adults, vary cost-sharing provisions, and provide
 4211  coverage for additional services. The agency shall evaluate the
 4212  proposed benefit packages to ensure that services are sufficient
 4213  to meet the needs of the plans’ enrollees and to verify
 4214  actuarial equivalence.
 4215         (4) For Medicaid recipients diagnosed with hemophilia who
 4216  have been prescribed anti-hemophilic-factor replacement
 4217  products, the agency shall provide for those products and
 4218  hemophilia overlay services through the agency’s hemophilia
 4219  disease management program authorized under s. 409.912.
 4220         (5) Managed care medical assistance services provided under
 4221  this section must be medically necessary and provided in
 4222  accordance with state and federal law. This section does not
 4223  prevent the agency from adjusting fees, reimbursement rates,
 4224  lengths of stay, number of visits, or number of services, or
 4225  from making any other adjustments necessary to comply with the
 4226  availability of funding and any limitations or directions
 4227  provided in the General Appropriations Act, chapter 216, or s.
 4228  409.9022.
 4229         Section 46. Section 409.973, Florida Statutes, is created
 4230  to read:
 4231         409.973Managed long-term care.—
 4232         (1) Qualified plans providing managed care medical
 4233  assistance may also participate in the managed long-term care
 4234  component of the Medicaid managed care program. Unless otherwise
 4235  specified, the provisions of ss. 409.961-409.970 apply to the
 4236  managed long-term care component of the managed care program.
 4237         (2) Pursuant to s. 409.902, the agency shall administer the
 4238  managed long-term care component described in this section and
 4239  ss. 409.974-409.978, but may delegate specific duties and
 4240  responsibilities to the Department of Elderly Affairs and other
 4241  state agencies. By March 31, 2012, the agency shall begin
 4242  implementation of the managed long-term care component, with
 4243  full implementation in all regions by March 31, 2013.
 4244         (3) The Department of Elderly Affairs shall assist the
 4245  agency in developing specifications for use in the invitation to
 4246  negotiate and the model contract, determining clinical
 4247  eligibility for enrollment in managed long-term care plans,
 4248  monitoring plan performance and measuring quality of service
 4249  delivery, assisting clients and families in order to address
 4250  complaints with the plans, facilitating working relationships
 4251  between plans and providers serving elders and disabled adults,
 4252  and performing other functions specified in a memorandum of
 4253  agreement.
 4254         Section 47. Section 409.974, Florida Statutes, is created
 4255  to read:
 4256         409.974Recipient eligibility for managed long-term care.—
 4257         (1) Medicaid recipients shall receive covered long-term
 4258  care services through the managed long-term care component of
 4259  the Medicaid managed care program unless excluded pursuant to s.
 4260  409.964. In order to participate in the managed long-term care
 4261  component, the recipient must be:
 4262         (a) Sixty-five years of age or older or eligible for
 4263  Medicaid by reason of a disability; and
 4264         (b)Determined by the Comprehensive Assessment and Review
 4265  for Long-Term Care Services (CARES) Program to meet the criteria
 4266  for nursing facility care.
 4267         (2) Medicaid recipients who are enrolled in one of the
 4268  following Medicaid long-term care waiver programs on the date
 4269  that a managed long-term care plan becomes available in the
 4270  recipient’s region may remain in that program if it is
 4271  operational on that date:
 4272         (a) The Assisted Living for the Frail Elderly Waiver.
 4273         (b) The Aged and Disabled Adult Waiver.
 4274         (c) The Adult Day Health Care Waiver.
 4275         (d) The Consumer-Directed Care Program as described in s.
 4276  409.221.
 4277         (e) The Program of All-inclusive Care for the Elderly.
 4278         (f) The Long-Term Care Community Diversion Pilot Project as
 4279  described in s. 430.705.
 4280         (g) The Channeling Services Waiver for Frail Elders.
 4281         (3) If a long-term care waiver program in which the
 4282  recipient is enrolled ceases to operate, the Medicaid recipient
 4283  may transfer to another long-term care waiver program or to the
 4284  Medicaid managed long-term care component of the Medicaid
 4285  managed care program. If no waivers are operational in the
 4286  recipient’s region and the recipient continues to participate in
 4287  Medicaid, the recipient must transfer to the managed long-term
 4288  care component of the Medicaid managed care program.
 4289         (4) New enrollment in a waiver program ends on the date
 4290  that a managed long-term care plan becomes available in a
 4291  region.
 4292         (5) Medicaid recipients who are residing in a nursing home
 4293  facility on the date that a managed long-term care plan becomes
 4294  available in the recipient’s region are eligible for the long
 4295  term care Medicaid waiver programs.
 4296         (6) This section does not create an entitlement to any home
 4297  and community-based services provided under the managed long
 4298  term care component.
 4299         Section 48. Section 409.975, Florida Statutes, is created
 4300  to read:
 4301         409.975Managed long-term care services.—
 4302         (1) Qualified plans participating in the managed long-term
 4303  care component of the Medicaid managed care program, at a
 4304  minimum, shall cover the following services:
 4305         (a) The services listed in s. 409.972.
 4306         (b) Nursing facility services.
 4307         (c) Home and community-based services, including, but not
 4308  limited to, assisted living facility services.
 4309         (2) Services provided under this section must be medically
 4310  necessary and provided in accordance with state and federal law.
 4311  This section does not prevent the agency from adjusting fees,
 4312  reimbursement rates, lengths of stay, number of visits, or
 4313  number of services, or from making any other adjustments
 4314  necessary to comply with the availability of funding and any
 4315  limitations or directions provided in the General Appropriations
 4316  Act, chapter 216, or s. 409.9022.
 4317         Section 49. Section 409.976, Florida Statutes, is created
 4318  to read:
 4319         409.976Qualified managed long-term care plans.—
 4320         (1) For purposes of managed long-term care, qualified plans
 4321  also include:
 4322         (a) Entities who are qualified under 42 C.F.R. part 422 as
 4323  Medicare Advantage Preferred Provider Organizations, Medicare
 4324  Advantage Provider-sponsored Organizations, and Medicare
 4325  Advantage Special Needs Plans. Such plans may participate in the
 4326  managed long-term care component. A plan submitting a response
 4327  to the invitation to negotiate for the managed long-term care
 4328  component may reference one or more of these entities as part of
 4329  its demonstration of network adequacy for the provision of
 4330  services required under s. 409.972 for dually eligible
 4331  enrollees.
 4332         (b)The Program of All-inclusive Care for the Elderly
 4333  (PACE). Participation by PACE shall be pursuant to a contract
 4334  with the agency and is not subject to the procurement
 4335  requirements of this section. PACE plans may continue to provide
 4336  services to recipients at such levels and enrollment caps as
 4337  authorized by the General Appropriations Act.
 4338         (2) The agency shall select qualified plans through the
 4339  procurement described in s. 409.965. The agency shall notice the
 4340  invitation to negotiate by November 14, 2011.
 4341         (3) In addition to the criteria established in s. 409.965,
 4342  the agency shall give preference to the following factors in
 4343  selecting qualified plans:
 4344         (a) The plan’s employment of executive managers having
 4345  expertise and experience in serving aged and disabled persons
 4346  who require long-term care.
 4347         (b) The plan’s establishment of a network of service
 4348  providers dispersed throughout the region and in sufficient
 4349  numbers to meet specific service standards established by the
 4350  agency for a continuum of care, beginning from the provision of
 4351  assistance with the activities of daily living at a recipient’s
 4352  home and the provision of other home and community-based care
 4353  through the provision of nursing home care. These providers
 4354  include:
 4355         1. Adult day centers.
 4356         2. Adult family care homes.
 4357         3. Assisted living facilities.
 4358         4. Health care services pools.
 4359         5. Home health agencies.
 4360         6. Homemaker and companion services.
 4361         7. Community Care for the Elderly lead agencies.
 4362         8. Nurse registries.
 4363         9. Nursing homes.
 4364  
 4365  All providers are not required to be located within the region;
 4366  however, the provider network must be sufficient to ensure that
 4367  services are available throughout the region.
 4368         (c) Whether a plan offers consumer-directed care services
 4369  to enrollees pursuant to s. 409.221 or includes attendant care
 4370  or paid family caregivers in the benefit package. Consumer
 4371  directed care services must provide a flexible budget, which is
 4372  managed by enrollees and their families or representatives, and
 4373  allows them to choose service providers, determine provider
 4374  rates of payment, and direct the delivery of services to best
 4375  meet their special long-term care needs. If all other factors
 4376  are equal among competing qualified plans, the agency shall give
 4377  preference to such plans.
 4378         (d) Evidence that a qualified plan has written agreements
 4379  or signed contracts or has made substantial progress in
 4380  establishing relationships with providers before the plan
 4381  submits a response.
 4382         (e) The availability and accessibility of case managers in
 4383  the plan and provider network.
 4384         Section 50. Section 409.977, Florida Statutes, is created
 4385  to read:
 4386         409.977Managed long-term plan and provider
 4387  accountability.—In addition to the requirements of ss. 409.966
 4388  and 409.967, plans and providers participating in managed long
 4389  term care must comply with s. 641.31(25) and with the specific
 4390  standards established by the agency for the number, type, and
 4391  regional distribution of the following providers in the plan’s
 4392  network, which must include:
 4393         (1) Adult day centers.
 4394         (2) Adult family care homes.
 4395         (3) Assisted living facilities.
 4396         (4) Health care services pools.
 4397         (5) Home health agencies.
 4398         (6) Homemaker and companion services.
 4399         (7) Community Care for the Elderly lead agencies.
 4400         (8) Nurse registries.
 4401         (9) Nursing homes.
 4402         Section 51. Section 409.978, Florida Statutes, is created
 4403  to read:
 4404         409.978CARES program screening; levels of care.—
 4405         (1) The agency shall operate the Comprehensive Assessment
 4406  and Review for Long-Term Care Services (CARES) preadmission
 4407  screening program to ensure that only recipients whose
 4408  conditions require long-term care services are enrolled in
 4409  managed long-term care plans.
 4410         (2) The agency shall operate the CARES program through an
 4411  interagency agreement with the Department of Elderly Affairs.
 4412  The agency, in consultation with the department, may contract
 4413  for any function or activity of the CARES program, including any
 4414  function or activity required by 42 C.F.R. part 483.20, relating
 4415  to preadmission screening and review.
 4416         (3) The CARES program shall determine if a recipient
 4417  requires nursing facility care and, if so, assign the recipient
 4418  to one of the following levels of care:
 4419         (a) Level of care 1 consists of enrollees who require the
 4420  constant availability of routine medical and nursing treatment
 4421  and care, have a limited need for health-related care and
 4422  services, are mildly medically or physically incapacitated, and
 4423  cannot be managed at home due to inadequacy of home-based
 4424  services.
 4425         (b) Level of care 2 consists of enrollees who require the
 4426  constant availability of routine medical and nursing treatment
 4427  and care, and require extensive health-related care and services
 4428  because of mental or physical incapacitation. Current enrollees
 4429  in home and community-based waiver programs for persons who are
 4430  elderly or adults with physical disability, or both, who remain
 4431  financially eligible for Medicaid are not required to meet new
 4432  level-of-care criteria except for immediate placement in a
 4433  nursing home.
 4434         (c) Level of care 3 consists of enrollees residing in
 4435  nursing homes, or needing immediate placement in a nursing home,
 4436  and who have a priority score of 5 or above as determined by
 4437  CARES.
 4438         (4) For recipients whose nursing home stay is initially
 4439  funded by Medicare and Medicare coverage is being terminated for
 4440  lack of progress towards rehabilitation, CARES staff shall
 4441  consult with the person determining the recipient’s progress
 4442  toward rehabilitation in order to ensure that the recipient is
 4443  not being inappropriately disqualified from Medicare coverage.
 4444  If, in their professional judgment, CARES staff believes that a
 4445  Medicare beneficiary is still making progress, they may assist
 4446  the Medicare beneficiary with appealing the disqualification
 4447  from Medicare coverage. The CARES teams may review Medicare
 4448  denials for coverage under this section only if it is determined
 4449  that such reviews qualify for federal matching funds through
 4450  Medicaid. The agency shall seek or amend federal waivers as
 4451  necessary to implement this section.
 4452         Section 52. Section 409.91207, Florida Statutes, is
 4453  transferred, renumbered as section 409.985, Florida Statutes,
 4454  and subsection (1) of that section is amended to read:
 4455         409.985 409.91207 Medical home pilot project.—
 4456         (1) The agency shall develop a plan to implement a medical
 4457  home pilot project that uses utilizes primary care case
 4458  management enhanced by medical home networks to provide
 4459  coordinated and cost-effective care that is reimbursed on a fee
 4460  for-service basis and to compare the performance of the medical
 4461  home networks with other existing Medicaid managed care models.
 4462  The agency may is authorized to seek a federal Medicaid waiver
 4463  or an amendment to any existing Medicaid waiver, except for the
 4464  current 1115 Medicaid waiver authorized in s. 409.986 409.91211,
 4465  as needed, to develop the pilot project created in this section
 4466  but must obtain approval of the Legislature before prior to
 4467  implementing the pilot project.
 4468         Section 53. Section 409.91211, Florida Statutes, is
 4469  transferred, renumbered as section 409.986, Florida Statutes,
 4470  and paragraph (aa) of subsection (3) and paragraph (a) of
 4471  subsection (4) of that section are amended, to read:
 4472         409.986 409.91211 Medicaid managed care pilot program.—
 4473         (3) The agency shall have the following powers, duties, and
 4474  responsibilities with respect to the pilot program:
 4475         (aa) To implement a mechanism whereby Medicaid recipients
 4476  who are already enrolled in a managed care plan or the MediPass
 4477  program in the pilot areas are shall be offered the opportunity
 4478  to change to capitated managed care plans on a staggered basis,
 4479  as defined by the agency. All Medicaid recipients shall have 30
 4480  days in which to make a choice of capitated managed care plans.
 4481  Those Medicaid recipients who do not make a choice shall be
 4482  assigned to a capitated managed care plan in accordance with
 4483  paragraph (4)(a) and shall be exempt from s. 409.987 409.9122.
 4484  To facilitate continuity of care for a Medicaid recipient who is
 4485  also a recipient of Supplemental Security Income (SSI), prior to
 4486  assigning the SSI recipient to a capitated managed care plan,
 4487  the agency shall determine whether the SSI recipient has an
 4488  ongoing relationship with a provider or capitated managed care
 4489  plan, and, if so, the agency shall assign the SSI recipient to
 4490  that provider or capitated managed care plan where feasible.
 4491  Those SSI recipients who do not have such a provider
 4492  relationship shall be assigned to a capitated managed care plan
 4493  provider in accordance with paragraph (4)(a) and shall be exempt
 4494  from s. 409.987 409.9122.
 4495         (4)(a) A Medicaid recipient in the pilot area who is not
 4496  currently enrolled in a capitated managed care plan upon
 4497  implementation is not eligible for services as specified in ss.
 4498  409.905 and 409.906, for the amount of time that the recipient
 4499  does not enroll in a capitated managed care network. If a
 4500  Medicaid recipient has not enrolled in a capitated managed care
 4501  plan within 30 days after eligibility, the agency shall assign
 4502  the Medicaid recipient to a capitated managed care plan based on
 4503  the assessed needs of the recipient as determined by the agency
 4504  and the recipient shall be exempt from s. 409.987 409.9122. When
 4505  making assignments, the agency shall take into account the
 4506  following criteria:
 4507         1. A capitated managed care network has sufficient network
 4508  capacity to meet the needs of members.
 4509         2. The capitated managed care network has previously
 4510  enrolled the recipient as a member, or one of the capitated
 4511  managed care network’s primary care providers has previously
 4512  provided health care to the recipient.
 4513         3. The agency has knowledge that the member has previously
 4514  expressed a preference for a particular capitated managed care
 4515  network as indicated by Medicaid fee-for-service claims data,
 4516  but has failed to make a choice.
 4517         4. The capitated managed care network’s primary care
 4518  providers are geographically accessible to the recipient’s
 4519  residence.
 4520         Section 54. Section 409.9122, Florida Statutes, is
 4521  transferred, renumbered as section 409.987, and paragraph (a) of
 4522  subsection (2) of that section is amended to read:
 4523         409.987 409.9122 Mandatory Medicaid managed care
 4524  enrollment; programs and procedures.—
 4525         (2)(a) The agency shall enroll all Medicaid recipients in a
 4526  managed care plan or MediPass all Medicaid recipients, except
 4527  those Medicaid recipients who are: in an institution, receiving
 4528  a Medicaid nonpoverty medical subsidy,; enrolled in the Medicaid
 4529  medically needy Program; or eligible for both Medicaid and
 4530  Medicare. Upon enrollment, recipients may individuals will be
 4531  able to change their managed care option during the 90-day opt
 4532  out period required by federal Medicaid regulations. The agency
 4533  may is authorized to seek the necessary Medicaid state plan
 4534  amendment to implement this policy. However, to the extent
 4535         1. If permitted by federal law, the agency may enroll in a
 4536  managed care plan or MediPass a Medicaid recipient who is exempt
 4537  from mandatory managed care enrollment in a managed care plan or
 4538  MediPass if, provided that:
 4539         a.1. The recipient’s decision to enroll in a managed care
 4540  plan or MediPass is voluntary;
 4541         b.2.If The recipient chooses to enroll in a managed care
 4542  plan, the agency has determined that the managed care plan
 4543  provides specific programs and services that which address the
 4544  special health needs of the recipient; and
 4545         c.3. The agency receives the any necessary waivers from the
 4546  federal Centers for Medicare and Medicaid Services.
 4547         2. The agency shall develop rules to establish policies by
 4548  which exceptions to the mandatory managed care enrollment
 4549  requirement may be made on a case-by-case basis. The rules must
 4550  shall include the specific criteria to be applied when
 4551  determining making a determination as to whether to exempt a
 4552  recipient from mandatory enrollment in a managed care plan or
 4553  MediPass.
 4554         3. School districts participating in the certified school
 4555  match program pursuant to ss. 409.908(21) and 1011.70 shall be
 4556  reimbursed by Medicaid, subject to the limitations of s.
 4557  1011.70(1), for a Medicaid-eligible child participating in the
 4558  services as authorized in s. 1011.70, as provided for in s.
 4559  409.9071, regardless of whether the child is enrolled in
 4560  MediPass or a managed care plan. Managed care plans must shall
 4561  make a good faith effort to execute agreements with school
 4562  districts regarding the coordinated provision of services
 4563  authorized under s. 1011.70.
 4564         4. County health departments delivering school-based
 4565  services pursuant to ss. 381.0056 and 381.0057 shall be
 4566  reimbursed by Medicaid for the federal share for a Medicaid
 4567  eligible child who receives Medicaid-covered services in a
 4568  school setting, regardless of whether the child is enrolled in
 4569  MediPass or a managed care plan. Managed care plans shall make a
 4570  good faith effort to execute agreements with county health
 4571  departments that coordinate the regarding the coordinated
 4572  provision of services to a Medicaid-eligible child. To ensure
 4573  continuity of care for Medicaid patients, the agency, the
 4574  Department of Health, and the Department of Education shall
 4575  develop procedures for ensuring that a student’s managed care
 4576  plan or MediPass provider receives information relating to
 4577  services provided in accordance with ss. 381.0056, 381.0057,
 4578  409.9071, and 1011.70.
 4579         Section 55. Section 409.9123, Florida Statutes, is
 4580  transferred and renumbered as section 409.988, Florida Statutes.
 4581         Section 56. Section 409.9124, Florida Statutes, is
 4582  transferred and renumbered as section 409.989.
 4583         Section 57. Subsection (15) of section 430.04, Florida
 4584  Statutes, is amended to read:
 4585         430.04 Duties and responsibilities of the Department of
 4586  Elderly Affairs.—The Department of Elderly Affairs shall:
 4587         (15) Administer all Medicaid waivers and programs relating
 4588  to elders and their appropriations. The waivers include, but are
 4589  not limited to:
 4590         (a) The Alzheimer’s Dementia-Specific Medicaid Waiver as
 4591  established in s. 430.502(7), (8), and (9).
 4592         (a)(b) The Assisted Living for the Frail Elderly Waiver.
 4593         (b)(c) The Aged and Disabled Adult Waiver.
 4594         (c)(d) The Adult Day Health Care Waiver.
 4595         (d)(e) The Consumer-Directed Care Plus Program as defined
 4596  in s. 409.221.
 4597         (e)(f) The Program of All-inclusive Care for the Elderly.
 4598         (f)(g) The Long-Term Care Community-Based Diversion Pilot
 4599  Project as described in s. 430.705.
 4600         (g)(h) The Channeling Services Waiver for Frail Elders.
 4601  
 4602  The department shall develop a transition plan for recipients
 4603  receiving services under long-term care Medicaid waivers for
 4604  elders or disabled adults on the date qualified plans become
 4605  available in each recipient’s region pursuant to s. 409.973(2)
 4606  in order to enroll those recipients in qualified plans.
 4607         Section 58. Section 430.2053, Florida Statutes, is amended
 4608  to read:
 4609         430.2053 Aging resource centers.—
 4610         (1) The department, in consultation with the Agency for
 4611  Health Care Administration and the Department of Children and
 4612  Family Services, shall develop pilot projects for aging resource
 4613  centers. By October 31, 2004, the department, in consultation
 4614  with the agency and the Department of Children and Family
 4615  Services, shall develop an implementation plan for aging
 4616  resource centers and submit the plan to the Governor, the
 4617  President of the Senate, and the Speaker of the House of
 4618  Representatives. The plan must include qualifications for
 4619  designation as a center, the functions to be performed by each
 4620  center, and a process for determining that a current area agency
 4621  on aging is ready to assume the functions of an aging resource
 4622  center.
 4623         (2) Each area agency on aging shall develop, in
 4624  consultation with the existing community care for the elderly
 4625  lead agencies within their planning and service areas, a
 4626  proposal that describes the process the area agency on aging
 4627  intends to undertake to transition to an aging resource center
 4628  prior to July 1, 2005, and that describes the area agency’s
 4629  compliance with the requirements of this section. The proposals
 4630  must be submitted to the department prior to December 31, 2004.
 4631  The department shall evaluate all proposals for readiness and,
 4632  prior to March 1, 2005, shall select three area agencies on
 4633  aging which meet the requirements of this section to begin the
 4634  transition to aging resource centers. Those area agencies on
 4635  aging which are not selected to begin the transition to aging
 4636  resource centers shall, in consultation with the department and
 4637  the existing community care for the elderly lead agencies within
 4638  their planning and service areas, amend their proposals as
 4639  necessary and resubmit them to the department prior to July 1,
 4640  2005. The department may transition additional area agencies to
 4641  aging resource centers as it determines that area agencies are
 4642  in compliance with the requirements of this section.
 4643         (3) The Auditor General and the Office of Program Policy
 4644  Analysis and Government Accountability (OPPAGA) shall jointly
 4645  review and assess the department’s process for determining an
 4646  area agency’s readiness to transition to an aging resource
 4647  center.
 4648         (a) The review must, at a minimum, address the
 4649  appropriateness of the department’s criteria for selection of an
 4650  area agency to transition to an aging resource center, the
 4651  instruments applied, the degree to which the department
 4652  accurately determined each area agency’s compliance with the
 4653  readiness criteria, the quality of the technical assistance
 4654  provided by the department to an area agency in correcting any
 4655  weaknesses identified in the readiness assessment, and the
 4656  degree to which each area agency overcame any identified
 4657  weaknesses.
 4658         (b) Reports of these reviews must be submitted to the
 4659  appropriate substantive and appropriations committees in the
 4660  Senate and the House of Representatives on March 1 and September
 4661  1 of each year until full transition to aging resource centers
 4662  has been accomplished statewide, except that the first report
 4663  must be submitted by February 1, 2005, and must address all
 4664  readiness activities undertaken through December 31, 2004. The
 4665  perspectives of all participants in this review process must be
 4666  included in each report.
 4667         (2)(4) The purposes of an aging resource center are shall
 4668  be:
 4669         (a) To provide Florida’s elders and their families with a
 4670  locally focused, coordinated approach to integrating information
 4671  and referral for all available services for elders with the
 4672  eligibility determination entities for state and federally
 4673  funded long-term-care services.
 4674         (b) To provide for easier access to long-term-care services
 4675  by Florida’s elders and their families by creating multiple
 4676  access points to the long-term-care network that flow through
 4677  one established entity with wide community recognition.
 4678         (3)(5) The duties of an aging resource center are to:
 4679         (a) Develop referral agreements with local community
 4680  service organizations, such as senior centers, existing elder
 4681  service providers, volunteer associations, and other similar
 4682  organizations, to better assist clients who do not need or do
 4683  not wish to enroll in programs funded by the department or the
 4684  agency. The referral agreements must also include a protocol,
 4685  developed and approved by the department, which provides
 4686  specific actions that an aging resource center and local
 4687  community service organizations must take when an elder or an
 4688  elder’s representative seeking information on long-term-care
 4689  services contacts a local community service organization prior
 4690  to contacting the aging resource center. The protocol shall be
 4691  designed to ensure that elders and their families are able to
 4692  access information and services in the most efficient and least
 4693  cumbersome manner possible.
 4694         (b) Provide an initial screening of all clients who request
 4695  long-term-care services to determine whether the person would be
 4696  most appropriately served through any combination of federally
 4697  funded programs, state-funded programs, locally funded or
 4698  community volunteer programs, or private funding for services.
 4699         (c) Determine eligibility for the programs and services
 4700  listed in subsection (9) (11) for persons residing within the
 4701  geographic area served by the aging resource center and
 4702  determine a priority ranking for services which is based upon
 4703  the potential recipient’s frailty level and likelihood of
 4704  institutional placement without such services.
 4705         (d) Manage the availability of financial resources for the
 4706  programs and services listed in subsection (9) (11) for persons
 4707  residing within the geographic area served by the aging resource
 4708  center.
 4709         (e) If When financial resources become available, refer a
 4710  client to the most appropriate entity to begin receiving
 4711  services. The aging resource center shall make referrals to lead
 4712  agencies for service provision that ensure that individuals who
 4713  are vulnerable adults in need of services pursuant to s.
 4714  415.104(3)(b), or who are victims of abuse, neglect, or
 4715  exploitation in need of immediate services to prevent further
 4716  harm and are referred by the adult protective services program,
 4717  are given primary consideration for receiving community-care
 4718  for-the-elderly services in compliance with the requirements of
 4719  s. 430.205(5)(a) and that other referrals for services are in
 4720  compliance with s. 430.205(5)(b).
 4721         (f) Convene a work group to advise in the planning,
 4722  implementation, and evaluation of the aging resource center. The
 4723  work group shall be composed comprised of representatives of
 4724  local service providers, Alzheimer’s Association chapters,
 4725  housing authorities, social service organizations, advocacy
 4726  groups, representatives of clients receiving services through
 4727  the aging resource center, and any other persons or groups as
 4728  determined by the department. The aging resource center, in
 4729  consultation with the work group, must develop annual program
 4730  improvement plans that shall be submitted to the department for
 4731  consideration. The department shall review each annual
 4732  improvement plan and make recommendations on how to implement
 4733  the components of the plan.
 4734         (g) Enhance the existing area agency on aging in each
 4735  planning and service area by integrating, either physically or
 4736  virtually, the staff and services of the area agency on aging
 4737  with the staff of the department’s local CARES Medicaid nursing
 4738  home preadmission screening unit and a sufficient number of
 4739  staff from the Department of Children and Family Services’
 4740  Economic Self-Sufficiency Unit necessary to determine the
 4741  financial eligibility for all persons age 60 and older residing
 4742  within the area served by the aging resource center who that are
 4743  seeking Medicaid services, Supplemental Security Income, and
 4744  food assistance.
 4745         (h) Assist clients who request long-term care services in
 4746  being evaluated for eligibility for the long-term care managed
 4747  care component of the Medicaid managed care program as qualified
 4748  plans become available in each of the regions pursuant to s.
 4749  409.973(2).
 4750         (i) Provide enrollment and coverage information to Medicaid
 4751  managed long-term care enrollees as qualified plans become
 4752  available in each of the regions pursuant to s. 409.973(2).
 4753         (j) Assist enrollees in the Medicaid long-term care managed
 4754  care program with informally resolving grievances with a managed
 4755  care network and in accessing the managed care network’s formal
 4756  grievance process as qualified plans become available in each of
 4757  the regions pursuant to s. 409.973(2).
 4758         (4)(6) The department shall select the entities to become
 4759  aging resource centers based on each entity’s readiness and
 4760  ability to perform the duties listed in subsection (3) (5) and
 4761  the entity’s:
 4762         (a) Expertise in the needs of each target population the
 4763  center proposes to serve and a thorough knowledge of the
 4764  providers that serve these populations.
 4765         (b) Strong connections to service providers, volunteer
 4766  agencies, and community institutions.
 4767         (c) Expertise in information and referral activities.
 4768         (d) Knowledge of long-term-care resources, including
 4769  resources designed to provide services in the least restrictive
 4770  setting.
 4771         (e) Financial solvency and stability.
 4772         (f) Ability to collect, monitor, and analyze data in a
 4773  timely and accurate manner, along with systems that meet the
 4774  department’s standards.
 4775         (g) Commitment to adequate staffing by qualified personnel
 4776  to effectively perform all functions.
 4777         (h) Ability to meet all performance standards established
 4778  by the department.
 4779         (5)(7) The aging resource center shall have a governing
 4780  body which shall be the same entity described in s. 20.41(7),
 4781  and an executive director who may be the same person as
 4782  described in s. 20.41(7). The governing body shall annually
 4783  evaluate the performance of the executive director.
 4784         (6)(8) The aging resource center may not be a provider of
 4785  direct services other than information and referral services,
 4786  and screening.
 4787         (7)(9) The aging resource center must agree to allow the
 4788  department to review any financial information the department
 4789  determines is necessary for monitoring or reporting purposes,
 4790  including financial relationships.
 4791         (8)(10) The duties and responsibilities of the community
 4792  care for the elderly lead agencies within each area served by an
 4793  aging resource center shall be to:
 4794         (a) Develop strong community partnerships to maximize the
 4795  use of community resources for the purpose of assisting elders
 4796  to remain in their community settings for as long as it is
 4797  safely possible.
 4798         (b) Conduct comprehensive assessments of clients that have
 4799  been determined eligible and develop a care plan consistent with
 4800  established protocols that ensures that the unique needs of each
 4801  client are met.
 4802         (9)(11) The services to be administered through the aging
 4803  resource center shall include those funded by the following
 4804  programs:
 4805         (a) Community care for the elderly.
 4806         (b) Home care for the elderly.
 4807         (c) Contracted services.
 4808         (d) Alzheimer’s disease initiative.
 4809         (e) Aged and disabled adult Medicaid waiver.
 4810         (f) Assisted living for the frail elderly Medicaid waiver.
 4811         (g) Older Americans Act.
 4812         (10)(12) The department shall, prior to designation of an
 4813  aging resource center, develop by rule operational and quality
 4814  assurance standards and outcome measures to ensure that clients
 4815  receiving services through all long-term-care programs
 4816  administered through an aging resource center are receiving the
 4817  appropriate care they require and that contractors and
 4818  subcontractors are adhering to the terms of their contracts and
 4819  are acting in the best interests of the clients they are
 4820  serving, consistent with the intent of the Legislature to reduce
 4821  the use of and cost of nursing home care. The department shall
 4822  by rule provide operating procedures for aging resource centers,
 4823  which shall include:
 4824         (a) Minimum standards for financial operation, including
 4825  audit procedures.
 4826         (b) Procedures for monitoring and sanctioning of service
 4827  providers.
 4828         (c) Minimum standards for technology utilized by the aging
 4829  resource center.
 4830         (d) Minimum staff requirements which shall ensure that the
 4831  aging resource center employs sufficient quality and quantity of
 4832  staff to adequately meet the needs of the elders residing within
 4833  the area served by the aging resource center.
 4834         (e) Minimum accessibility standards, including hours of
 4835  operation.
 4836         (f) Minimum oversight standards for the governing body of
 4837  the aging resource center to ensure its continuous involvement
 4838  in, and accountability for, all matters related to the
 4839  development, implementation, staffing, administration, and
 4840  operations of the aging resource center.
 4841         (g) Minimum education and experience requirements for
 4842  executive directors and other executive staff positions of aging
 4843  resource centers.
 4844         (h) Minimum requirements regarding any executive staff
 4845  positions that the aging resource center must employ and minimum
 4846  requirements that a candidate must meet in order to be eligible
 4847  for appointment to such positions.
 4848         (11)(13) In an area in which the department has designated
 4849  an area agency on aging as an aging resource center, the
 4850  department and the agency may shall not make payments for the
 4851  services listed in subsection (9) (11) and the Long-Term Care
 4852  Community Diversion Project for such persons who were not
 4853  screened and enrolled through the aging resource center. The
 4854  department shall cease making these payments for enrollees in
 4855  qualified plans as qualified plans become available in each of
 4856  the regions pursuant to s. 409.973(2).
 4857         (12)(14) Each aging resource center shall enter into a
 4858  memorandum of understanding with the department for
 4859  collaboration with the CARES unit staff. The memorandum of
 4860  understanding must shall outline the staff person responsible
 4861  for each function and shall provide the staffing levels
 4862  necessary to carry out the functions of the aging resource
 4863  center.
 4864         (13)(15) Each aging resource center shall enter into a
 4865  memorandum of understanding with the Department of Children and
 4866  Family Services for collaboration with the Economic Self
 4867  Sufficiency Unit staff. The memorandum of understanding must
 4868  shall outline which staff persons are responsible for which
 4869  functions and shall provide the staffing levels necessary to
 4870  carry out the functions of the aging resource center.
 4871         (14)(16) If any of the state activities described in this
 4872  section are outsourced, either in part or in whole, the contract
 4873  executing the outsourcing must shall mandate that the contractor
 4874  or its subcontractors shall, either physically or virtually,
 4875  execute the provisions of the memorandum of understanding
 4876  instead of the state entity whose function the contractor or
 4877  subcontractor now performs.
 4878         (15)(17) In order to be eligible to begin transitioning to
 4879  an aging resource center, an area agency on aging board must
 4880  ensure that the area agency on aging which it oversees meets all
 4881  of the minimum requirements set by law and in rule.
 4882         (18) The department shall monitor the three initial
 4883  projects for aging resource centers and report on the progress
 4884  of those projects to the Governor, the President of the Senate,
 4885  and the Speaker of the House of Representatives by June 30,
 4886  2005. The report must include an evaluation of the
 4887  implementation process.
 4888         (16)(19)(a) Once an aging resource center is operational,
 4889  the department, in consultation with the agency, may develop
 4890  capitation rates for any of the programs administered through
 4891  the aging resource center. Capitation rates for programs must
 4892  shall be based on the historical cost experience of the state in
 4893  providing those same services to the population age 60 or older
 4894  residing within each area served by an aging resource center.
 4895  Each capitated rate may vary by geographic area as determined by
 4896  the department.
 4897         (b) The department and the agency may determine for each
 4898  area served by an aging resource center whether it is
 4899  appropriate, consistent with federal and state laws and
 4900  regulations, to develop and pay separate capitated rates for
 4901  each program administered through the aging resource center or
 4902  to develop and pay capitated rates for service packages which
 4903  include more than one program or service administered through
 4904  the aging resource center.
 4905         (c) Once capitation rates have been developed and certified
 4906  as actuarially sound, the department and the agency may pay
 4907  service providers the capitated rates for services if when
 4908  appropriate.
 4909         (d) The department, in consultation with the agency, shall
 4910  annually reevaluate and recertify the capitation rates,
 4911  adjusting forward to account for inflation, programmatic
 4912  changes.
 4913         (20) The department, in consultation with the agency, shall
 4914  submit to the Governor, the President of the Senate, and the
 4915  Speaker of the House of Representatives, by December 1, 2006, a
 4916  report addressing the feasibility of administering the following
 4917  services through aging resource centers beginning July 1, 2007:
 4918         (a) Medicaid nursing home services.
 4919         (b) Medicaid transportation services.
 4920         (c) Medicaid hospice care services.
 4921         (d) Medicaid intermediate care services.
 4922         (e) Medicaid prescribed drug services.
 4923         (f) Medicaid assistive care services.
 4924         (g) Any other long-term-care program or Medicaid service.
 4925         (17)(21) This section does shall not be construed to allow
 4926  an aging resource center to restrict, manage, or impede the
 4927  local fundraising activities of service providers.
 4928         Section 59. Paragraphs (c) and (d) of subsection (3) of
 4929  section 39.407, Florida Statutes, are amended to read:
 4930         39.407 Medical, psychiatric, and psychological examination
 4931  and treatment of child; physical, mental, or substance abuse
 4932  examination of person with or requesting child custody.—
 4933         (3)
 4934         (c) Except as provided in paragraphs (b) and (e), the
 4935  department must file a motion seeking the court’s authorization
 4936  to initially provide or continue to provide psychotropic
 4937  medication to a child in its legal custody. The motion must be
 4938  supported by a written report prepared by the department which
 4939  describes the efforts made to enable the prescribing physician
 4940  to obtain express and informed consent to provide for providing
 4941  the medication to the child and other treatments considered or
 4942  recommended for the child. In addition, The motion must also be
 4943  supported by the prescribing physician’s signed medical report
 4944  providing:
 4945         1. The name of the child, the name and range of the dosage
 4946  of the psychotropic medication, and the that there is a need to
 4947  prescribe psychotropic medication to the child based upon a
 4948  diagnosed condition for which such medication is being
 4949  prescribed.
 4950         2. A statement indicating that the physician has reviewed
 4951  all medical information concerning the child which has been
 4952  provided.
 4953         3. A statement indicating that the psychotropic medication,
 4954  at its prescribed dosage, is appropriate for treating the
 4955  child’s diagnosed medical condition, as well as the behaviors
 4956  and symptoms the medication, at its prescribed dosage, is
 4957  expected to address.
 4958         4. An explanation of the nature and purpose of the
 4959  treatment; the recognized side effects, risks, and
 4960  contraindications of the medication; drug-interaction
 4961  precautions; the possible effects of stopping the medication;
 4962  and how the treatment will be monitored, followed by a statement
 4963  indicating that this explanation was provided to the child if
 4964  age appropriate and to the child’s caregiver.
 4965         5. Documentation addressing whether the psychotropic
 4966  medication will replace or supplement any other currently
 4967  prescribed medications or treatments; the length of time the
 4968  child is expected to be taking the medication; and any
 4969  additional medical, mental health, behavioral, counseling, or
 4970  other services that the prescribing physician recommends.
 4971         6. For a child 10 years of age or younger who is in an out
 4972  of-home placement, the results of a review of the administration
 4973  of the medication by a child psychiatrist who is licensed under
 4974  chapter 458 or chapter 459. The review must be provided to the
 4975  child and the parent or legal guardian before final express and
 4976  informed consent is given. The review must include a
 4977  determination of the following:
 4978         a. The presence of a genetic psychiatric disorder or a
 4979  family history of a psychiatric disorder;
 4980         b. Whether the cause of a psychiatric disorder is physical
 4981  or environmental; and
 4982         c. The likelihood of the child being an imminent danger to
 4983  self or others.
 4984         (d)1. The department must notify all parties of the
 4985  proposed action taken under paragraph (c) in writing or by
 4986  whatever other method best ensures that all parties receive
 4987  notification of the proposed action within 48 hours after the
 4988  motion is filed. If any party objects to the department’s
 4989  motion, that party shall file the objection within 2 working
 4990  days after being notified of the department’s motion. If any
 4991  party files an objection to the authorization of the proposed
 4992  psychotropic medication, the court shall hold a hearing as soon
 4993  as possible before authorizing the department to initially
 4994  provide or to continue providing psychotropic medication to a
 4995  child in the legal custody of the department.
 4996         1. At such hearing and notwithstanding s. 90.803, the
 4997  medical report described in paragraph (c) is admissible in
 4998  evidence. The prescribing physician need not attend the hearing
 4999  or testify unless the court specifically orders such attendance
 5000  or testimony, or a party subpoenas the physician to attend the
 5001  hearing or provide testimony.
 5002         2. If, after considering any testimony received, the court
 5003  finds that the department’s motion and the physician’s medical
 5004  report meet the requirements of this subsection and that it is
 5005  in the child’s best interests, the court may order that the
 5006  department provide or continue to provide the psychotropic
 5007  medication to the child without additional testimony or
 5008  evidence.
 5009         3. At any hearing held under this paragraph, the court
 5010  shall further inquire of the department as to whether additional
 5011  medical, mental health, behavioral, counseling, or other
 5012  services are being provided to the child by the department which
 5013  the prescribing physician considers to be necessary or
 5014  beneficial in treating the child’s medical condition and which
 5015  the physician recommends or expects to provide to the child in
 5016  concert with the medication. The court may order additional
 5017  medical consultation, including consultation with the MedConsult
 5018  line at the University of Florida, if available, or require the
 5019  department to obtain a second opinion within a reasonable
 5020  timeframe as established by the court, not to exceed 21 calendar
 5021  days, after such order based upon consideration of the best
 5022  interests of the child. The department must make a referral for
 5023  an appointment for a second opinion with a physician within 1
 5024  working day.
 5025         4. The court may not order the discontinuation of
 5026  prescribed psychotropic medication if such order is contrary to
 5027  the decision of the prescribing physician unless the court first
 5028  obtains an opinion from a licensed psychiatrist, if available,
 5029  or, if not available, a physician licensed under chapter 458 or
 5030  chapter 459, stating that more likely than not, discontinuing
 5031  the medication would not cause significant harm to the child.
 5032  If, however, the prescribing psychiatrist specializes in mental
 5033  health care for children and adolescents, the court may not
 5034  order the discontinuation of prescribed psychotropic medication
 5035  unless the required opinion is also from a psychiatrist who
 5036  specializes in mental health care for children and adolescents.
 5037  The court may also order the discontinuation of prescribed
 5038  psychotropic medication if a child’s treating physician,
 5039  licensed under chapter 458 or chapter 459, states that
 5040  continuing the prescribed psychotropic medication would cause
 5041  significant harm to the child due to a diagnosed nonpsychiatric
 5042  medical condition.
 5043         5. If a child who is in out-of-home placement is 10 years
 5044  of age or younger, psychotropic medication may not be authorized
 5045  by the court absent a finding of a compelling governmental
 5046  interest. In making such finding, the court shall review the
 5047  psychiatric review described in subparagraph (c)6.
 5048         6.2. The burden of proof at any hearing held under this
 5049  paragraph shall be by a preponderance of the evidence.
 5050         Section 60. Paragraph (a) of subsection (1) of section
 5051  216.262, Florida Statutes, is amended to read:
 5052         216.262 Authorized positions.—
 5053         (1)(a) Except as Unless otherwise expressly provided by
 5054  law, the total number of authorized positions may not exceed the
 5055  total provided in the appropriations acts. If a In the event any
 5056  state agency or entity of the judicial branch finds that the
 5057  number of positions so provided is not sufficient to administer
 5058  its authorized programs, it may file an application with the
 5059  Executive Office of the Governor or the Chief Justice; and, if
 5060  the Executive Office of the Governor or Chief Justice certifies
 5061  that there are no authorized positions available for addition,
 5062  deletion, or transfer within the agency or entity as provided in
 5063  paragraph (c), may recommend and recommends an increase in the
 5064  number of positions.,
 5065         1. The Governor or the Chief Justice may recommend an
 5066  increase in the number of positions for the following reasons
 5067  only:
 5068         a.1. To implement or provide for continuing federal grants
 5069  or changes in grants not previously anticipated.
 5070         b.2. To meet emergencies pursuant to s. 252.36.
 5071         c.3. To satisfy new federal regulations or changes therein.
 5072         d.4. To take advantage of opportunities to reduce operating
 5073  expenditures or to increase the revenues of the state or local
 5074  government.
 5075         e.5. To authorize positions that were not fixed by the
 5076  Legislature due to through error in drafting the appropriations
 5077  acts.
 5078         2. Actions recommended pursuant to this paragraph are
 5079  subject to approval by the Legislative Budget Commission. The
 5080  certification and the final authorization shall be provided to
 5081  the Legislative Budget Commission, the legislative
 5082  appropriations committees, and the Auditor General.
 5083         3. The provisions of this paragraph do not apply to
 5084  positions in the Department of Health which are funded by the
 5085  County Health Department Trust Fund.
 5086         Section 61. Section 381.06014, Florida Statutes, is amended
 5087  to read:
 5088         381.06014 Blood establishments.—
 5089         (1) As used in this section, the term:
 5090         (a) “Blood establishment” means any person, entity, or
 5091  organization, operating within the state, which examines an
 5092  individual for the purpose of blood donation or which collects,
 5093  processes, stores, tests, or distributes blood or blood
 5094  components collected from the human body for the purpose of
 5095  transfusion, for any other medical purpose, or for the
 5096  production of any biological product. A person, entity, or
 5097  organization that uses a mobile unit to conduct such activities
 5098  within the state is also a blood establishment.
 5099         (b) “Volunteer donor” means a person who does not receive
 5100  remuneration, other than an incentive, for a blood donation
 5101  intended for transfusion, and the product container of the
 5102  donation from the person qualifies for labeling with the
 5103  statement “volunteer donor” under 21 C.F.R. s. 606.121.
 5104         (2) An entity or organization may not hold itself out and
 5105  engage in the activities of a Any blood establishment in this
 5106  state operating in the state may not conduct any activity
 5107  defined in subsection (1) unless it operates in accordance that
 5108  blood establishment is operated in a manner consistent with the
 5109  provisions of Title 21 C.F.R. parts 211 and 600-640, Code of
 5110  Federal Regulations.
 5111         (3) A Any blood establishment determined to be operating in
 5112  the state in a manner not consistent with the provisions of
 5113  Title 21 C.F.R. parts 211 and 600-640, Code of Federal
 5114  Regulations, and in a manner that constitutes a danger to the
 5115  health or well-being of donors or recipients as evidenced by the
 5116  federal Food and Drug Administration’s inspection reports and
 5117  the revocation of the blood establishment’s license or
 5118  registration is shall be in violation of this chapter, and shall
 5119  immediately cease all operations in the state.
 5120         (4) The operation of a blood establishment in a manner not
 5121  consistent with the provisions of Title 21 parts 211 and 600
 5122  640, Code of Federal Regulations, and in a manner that
 5123  constitutes a danger to the health or well-being of blood donors
 5124  or recipients as evidenced by the federal Food and Drug
 5125  Administration’s inspection process is declared a nuisance and
 5126  inimical to the public health, welfare, and safety, and must
 5127  immediately cease all operations in this state. The Agency for
 5128  Health Care Administration or any state attorney may bring an
 5129  action for an injunction to restrain such operations or enjoin
 5130  the future operation of the blood establishment.
 5131         (4) A local government may not restrict access to or the
 5132  use of any public facility or infrastructure for the collection
 5133  of blood or blood components from volunteer donors based on
 5134  whether the blood establishment is operating as a for-profit or
 5135  not-for-profit organization.
 5136         (5) In determining the service fee of blood or blood
 5137  components received from volunteer donors and sold to hospitals
 5138  or other health care providers, a blood establishment may not
 5139  base the service fee of the blood or blood component solely on
 5140  whether the purchasing entity is a for-profit or not-for-profit
 5141  organization.
 5142         (6) A blood establishment that collects blood or blood
 5143  components from volunteer donors must disclose the following
 5144  information on its Internet website in order to educate and
 5145  inform donors and the public about the blood establishment’s
 5146  activities, and the information required to be disclosed may be
 5147  cumulative for all blood establishments within a business
 5148  entity:
 5149         (a) A description of the steps involved in collecting,
 5150  processing, and distributing volunteer donations.
 5151         (b) By March 1 of each year, the number of units of blood
 5152  components which were:
 5153         1. Produced by the blood establishment during the preceding
 5154  calendar year;
 5155         2. Obtained from other sources during the preceding
 5156  calendar year;
 5157         3. Distributed during the preceding calendar year to health
 5158  care providers located outside this state. However, if the blood
 5159  establishment collects donations in a county outside this state,
 5160  distributions to health care providers in that county are
 5161  excluded. Such information shall be reported in the aggregate
 5162  for health care providers located within the United States and
 5163  its territories or outside the United States and its
 5164  territories; and
 5165         4. Distributed during the preceding calendar year to
 5166  entities that are not health care providers. Such information
 5167  shall be reported in the aggregate for purchasers located within
 5168  the United States and its territories or outside the United
 5169  States and its territories.
 5170         (c) The blood establishment’s conflict-of-interest policy,
 5171  policy concerning related-party transactions, whistleblower
 5172  policy, and policy for determining executive compensation. If a
 5173  change occurs to any of these documents, the revised document
 5174  must be available on the blood establishment’s website by the
 5175  following March 1.
 5176         (d) Except for a hospital that collects blood or blood
 5177  components from volunteer donors:
 5178         1. The most recent 3 years of the Return of Organization
 5179  Exempt from Income Tax, Internal Revenue Service Form 990, if
 5180  the business entity for the blood establishment is eligible to
 5181  file such return. The Form 990 must be available on the blood
 5182  establishment’s website within 60 calendar days after it is
 5183  filed with the Internal Revenue Service; or
 5184         2. If the business entity for the blood establishment is
 5185  not eligible to file the Form 990 return, a balance sheet,
 5186  income statement, and statement of changes in cash flow, along
 5187  with the expression of an opinion thereon by an independent
 5188  certified public accountant who audited or reviewed such
 5189  financial statements. Such documents must be available on the
 5190  blood establishment’s website within 120 days after the end of
 5191  the blood establishment’s fiscal year and must remain on the
 5192  blood establishment’s website for at least 36 months.
 5193  
 5194  A hospital that collects blood or blood components to be used
 5195  only by that hospital’s licensed facilities or by a health care
 5196  provider that is a part of the hospital’s business entity is
 5197  exempt from the disclosure requirements of this subsection.
 5198         (7) A blood establishment is liable for a civil penalty for
 5199  failing to make the disclosures required under subsection (6).
 5200  The Department of Legal Affairs may assess a civil penalty
 5201  against the blood establishment for each day that it fails to
 5202  make such required disclosures, but the penalty may not exceed
 5203  $10,000 per year. If multiple blood establishments operated by a
 5204  single business entity fail to meet such disclosure
 5205  requirements, the civil penalty may be assessed against only one
 5206  of the business entity’s blood establishments. The Department of
 5207  Legal Affairs may terminate an action if the blood establishment
 5208  agrees to pay a stipulated civil penalty. A civil penalty so
 5209  collected accrues to the state and shall be deposited as
 5210  received into the General Revenue Fund unallocated. The
 5211  Department of Legal Affairs may terminate the action and waive
 5212  the civil penalty upon a showing of good cause by the blood
 5213  establishment as to why the required disclosures were not made.
 5214         Section 62. Subsection (9) of section 393.063, Florida
 5215  Statutes, is amended, present subsections (13) through (40) of
 5216  that section are redesignated as subsections (14) through (41),
 5217  respectively, and a new subsection (13) is added to that
 5218  section, to read:
 5219         393.063 Definitions.—For the purposes of this chapter, the
 5220  term:
 5221         (9) “Developmental disability” means a disorder or syndrome
 5222  that is attributable to retardation, cerebral palsy, autism,
 5223  spina bifida, Down syndrome, or Prader-Willi syndrome; that
 5224  manifests before the age of 18; and that constitutes a
 5225  substantial handicap that can reasonably be expected to continue
 5226  indefinitely.
 5227         (13) “Down syndrome” means a disorder that is caused by the
 5228  presence of an extra chromosome 21.
 5229         Section 63. Section 400.023, Florida Statutes, is reordered
 5230  and amended to read:
 5231         400.023 Civil enforcement.—
 5232         (1) A Any resident who whose alleges negligence or a
 5233  violation of rights as specified in this part has are violated
 5234  shall have a cause of action against the licensee or its
 5235  management company, as identified in the state application for
 5236  nursing home licensure. However, the cause of action may not be
 5237  asserted individually against an officer, director, owner,
 5238  including an owner designated as having a controlling interest
 5239  on the state application for nursing home licensure, or agent of
 5240  a licensee or management company unless, following an
 5241  evidentiary hearing, the court determines there is sufficient
 5242  evidence in the record or proffered by the claimant which
 5243  establishes a reasonable basis for finding that the person or
 5244  entity breached, failed to perform, or acted outside the scope
 5245  of duties as an officer, director, owner, or agent, and that the
 5246  breach, failure to perform, or action outside the scope of
 5247  duties is a legal cause of actual loss, injury, death, or damage
 5248  to the resident.
 5249         (2) The action may be brought by the resident or his or her
 5250  guardian, by a person or organization acting on behalf of a
 5251  resident with the consent of the resident or his or her
 5252  guardian, or by the personal representative of the estate of a
 5253  deceased resident regardless of the cause of death.
 5254         (5) If the action alleges a claim for the resident’s rights
 5255  or for negligence that:
 5256         (a) Caused the death of the resident, the claimant must
 5257  shall be required to elect either survival damages pursuant to
 5258  s. 46.021 or wrongful death damages pursuant to s. 768.21. If
 5259  the claimant elects wrongful death damages, total noneconomic
 5260  damages may not exceed $250,000, regardless of the number of
 5261  claimants.
 5262         (b)If the action alleges a claim for the resident’s rights
 5263  or for negligence that Did not cause the death of the resident,
 5264  the personal representative of the estate may recover damages
 5265  for the negligence that caused injury to the resident.
 5266         (3) The action may be brought in any court of competent
 5267  jurisdiction to enforce such rights and to recover actual and
 5268  punitive damages for any violation of the rights of a resident
 5269  or for negligence.
 5270         (10) Any resident who prevails in seeking injunctive relief
 5271  or a claim for an administrative remedy may is entitled to
 5272  recover the costs of the action, and a reasonable attorney’s fee
 5273  assessed against the defendant not to exceed $25,000. Fees shall
 5274  be awarded solely for the injunctive or administrative relief
 5275  and not for any claim or action for damages whether such claim
 5276  or action is brought together with a request for an injunction
 5277  or administrative relief or as a separate action, except as
 5278  provided under s. 768.79 or the Florida Rules of Civil
 5279  Procedure. Sections 400.023-400.0238 provide the exclusive
 5280  remedy for a cause of action for recovery of damages for the
 5281  personal injury or death of a nursing home resident arising out
 5282  of negligence or a violation of rights specified in s. 400.022.
 5283  This section does not preclude theories of recovery not arising
 5284  out of negligence or s. 400.022 which are available to a
 5285  resident or to the agency. The provisions of chapter 766 do not
 5286  apply to any cause of action brought under ss. 400.023-400.0238.
 5287         (6)(2)If the In any claim brought pursuant to this part
 5288  alleges alleging a violation of resident’s rights or negligence
 5289  causing injury to or the death of a resident, the claimant shall
 5290  have the burden of proving, by a preponderance of the evidence,
 5291  that:
 5292         (a) The defendant owed a duty to the resident;
 5293         (b) The defendant breached the duty to the resident;
 5294         (c) The breach of the duty is a legal cause of loss,
 5295  injury, death, or damage to the resident; and
 5296         (d) The resident sustained loss, injury, death, or damage
 5297  as a result of the breach.
 5298         (12) Nothing in This part does not shall be interpreted to
 5299  create strict liability. A violation of the rights set forth in
 5300  s. 400.022 or in any other standard or guidelines specified in
 5301  this part or in any applicable administrative standard or
 5302  guidelines of this state or a federal regulatory agency is shall
 5303  be evidence of negligence but may shall not be considered
 5304  negligence per se.
 5305         (7)(3) In any claim brought pursuant to this section, a
 5306  licensee, person, or entity has shall have a duty to exercise
 5307  reasonable care. Reasonable care is that degree of care which a
 5308  reasonably careful licensee, person, or entity would use under
 5309  like circumstances.
 5310         (9)(4) In any claim for resident’s rights violation or
 5311  negligence by a nurse licensed under part I of chapter 464, such
 5312  nurse has a shall have the duty to exercise care consistent with
 5313  the prevailing professional standard of care for a nurse. The
 5314  prevailing professional standard of care for a nurse is shall be
 5315  that level of care, skill, and treatment which, in light of all
 5316  relevant surrounding circumstances, is recognized as acceptable
 5317  and appropriate by reasonably prudent similar nurses.
 5318         (8)(5) A licensee is shall not be liable for the medical
 5319  negligence of any physician rendering care or treatment to the
 5320  resident except for the administrative services of a medical
 5321  director as required in this part. Nothing in This subsection
 5322  does not shall be construed to protect a licensee, person, or
 5323  entity from liability for failure to provide a resident with
 5324  appropriate observation, assessment, nursing diagnosis,
 5325  planning, intervention, and evaluation of care by nursing staff.
 5326         (4)(6) The resident or the resident’s legal representative
 5327  shall serve a copy of any complaint alleging in whole or in part
 5328  a violation of any rights specified in this part to the agency
 5329  for Health Care Administration at the time of filing the initial
 5330  complaint with the clerk of the court for the county in which
 5331  the action is pursued. The requirement of Providing a copy of
 5332  the complaint to the agency does not impair the resident’s legal
 5333  rights or ability to seek relief for his or her claim.
 5334         (11)(7) An action under this part for a violation of rights
 5335  or negligence recognized herein is not a claim for medical
 5336  malpractice, and the provisions of s. 768.21(8) do not apply to
 5337  a claim alleging death of the resident.
 5338         Section 64. Subsections (1), (2), and (3) of section
 5339  400.0237, Florida Statutes, are amended to read:
 5340         400.0237 Punitive damages; pleading; burden of proof.—
 5341         (1) In any action for damages brought under this part, a no
 5342  claim for punitive damages is not shall be permitted unless,
 5343  based on admissible there is a reasonable showing by evidence in
 5344  the record or proffered by the claimant, which would provide a
 5345  reasonable basis for recovery of such damages is demonstrated
 5346  upon applying the criteria set forth in this section. The
 5347  defendant may proffer admissible evidence to refute the
 5348  claimant’s proffer of evidence to recover punitive damages. The
 5349  trial judge shall conduct an evidentiary hearing and weigh the
 5350  admissible evidence proffered by the claimant and the defendant
 5351  to ensure that there is a reasonable basis to believe that the
 5352  claimant, at trial, will be able to demonstrate by clear and
 5353  convincing evidence that the recovery of such damages is
 5354  warranted. The claimant may move to amend her or his complaint
 5355  to assert a claim for punitive damages as allowed by the rules
 5356  of civil procedure. The rules of civil procedure shall be
 5357  liberally construed so as to allow the claimant discovery of
 5358  evidence which appears reasonably calculated to lead to
 5359  admissible evidence on the issue of punitive damages. No
 5360  Discovery of financial worth may not shall proceed until after
 5361  the trial judge approves the pleading on concerning punitive
 5362  damages is permitted.
 5363         (2) A defendant, including the licensee or management
 5364  company, against whom punitive damages is sought may be held
 5365  liable for punitive damages only if the trier of fact, based on
 5366  clear and convincing evidence, finds that a specific individual
 5367  or corporate defendant actively and knowingly participated in
 5368  intentional misconduct, or engaged in conduct that constituted
 5369  gross negligence, and that conduct contributed to the loss,
 5370  damages, or injury suffered by the claimant the defendant was
 5371  personally guilty of intentional misconduct or gross negligence.
 5372  As used in this section, the term:
 5373         (a) “Intentional misconduct” means that the defendant
 5374  against whom a claim for punitive damages is sought had actual
 5375  knowledge of the wrongfulness of the conduct and the high
 5376  probability that injury or damage to the claimant would result
 5377  and, despite that knowledge, intentionally pursued that course
 5378  of conduct, resulting in injury or damage.
 5379         (b) “Gross negligence” means that the defendant’s conduct
 5380  was so reckless or wanting in care that it constituted a
 5381  conscious disregard or indifference to the life, safety, or
 5382  rights of persons exposed to such conduct.
 5383         (3) In the case of vicarious liability of an employer,
 5384  principal, corporation, or other legal entity, punitive damages
 5385  may not be imposed for the conduct of an identified employee or
 5386  agent unless only if the conduct of the employee or agent meets
 5387  the criteria specified in subsection (2) and officers,
 5388  directors, or managers of the actual employer corporation or
 5389  legal entity condoned, ratified, or consented to the specific
 5390  conduct as alleged by the claimant in subsection (2).:
 5391         (a) The employer, principal, corporation, or other legal
 5392  entity actively and knowingly participated in such conduct;
 5393         (b) The officers, directors, or managers of the employer,
 5394  principal, corporation, or other legal entity condoned,
 5395  ratified, or consented to such conduct; or
 5396         (c) The employer, principal, corporation, or other legal
 5397  entity engaged in conduct that constituted gross negligence and
 5398  that contributed to the loss, damages, or injury suffered by the
 5399  claimant.
 5400         Section 65. Subsections (3) and (4) of section 408.7057,
 5401  Florida Statutes, are amended, present subsection (7) of that
 5402  section is redesignated as subsection (8), and a new subsection
 5403  (7) is added to that section, to read:
 5404         408.7057 Statewide provider and health plan claim dispute
 5405  resolution program.—
 5406         (3) The agency shall adopt rules to establish a process to
 5407  be used by the resolution organization in considering claim
 5408  disputes submitted by a provider or health plan which must
 5409  include a hearing, if requested by the respondent, and the
 5410  issuance by the resolution organization of a written
 5411  recommendation, supported by findings of fact and conclusions of
 5412  law, to the agency within 60 days after the requested
 5413  information is received by the resolution organization within
 5414  the timeframes specified by the resolution organization. In no
 5415  event shall The review time may not exceed 90 days following
 5416  receipt of the initial claim dispute submission by the
 5417  resolution organization.
 5418         (4) Within 30 days after receipt of the recommendation of
 5419  the resolution organization, the agency shall adopt the
 5420  recommendation as a final order subject to chapter 120.
 5421         (7) This section creates a procedure for dispute resolution
 5422  and not an independent right of recovery. The conclusions of law
 5423  contained in the written recommendation of the resolution
 5424  organization must identify the provisions of law or contract
 5425  which, under the particular facts and circumstances of the case,
 5426  entitle the provider or health plan to the amount awarded, if
 5427  any.
 5428         Section 66. Section 458.3167, Florida Statutes, is created
 5429  to read:
 5430         458.3167Expert witness certificate.—
 5431         (1) A physician who holds an active and valid license to
 5432  practice allopathic medicine in any other state or in Canada,
 5433  who submits an application form prescribed by the board to
 5434  obtain a certificate to provide expert testimony and pays the
 5435  application fee, and who has not had a previous expert witness
 5436  certificate revoked by the board shall be issued a certificate
 5437  to provide expert testimony.
 5438         (2) A physician possessing an expert witness certificate
 5439  may use the certificate only to give a verified written medical
 5440  expert opinion as provided in s. 766.203 and to provide expert
 5441  testimony concerning the prevailing professional standard of
 5442  care for medical negligence litigation pending in this state
 5443  against a physician licensed under this chapter or chapter 459.
 5444         (3) An application for an expert witness certificate must
 5445  be approved or denied within 5 business days after receipt of a
 5446  completed application. An application that is not approved or
 5447  denied within the required time period is deemed approved. An
 5448  applicant seeking to claim certification by default shall notify
 5449  the board, in writing, of the intent to rely on the default
 5450  certification provision of this subsection. In such case, s.
 5451  458.327 does not apply, and the applicant may provide expert
 5452  testimony as provided in subsection (2).
 5453         (4) All licensure fees, other than the initial certificate
 5454  application fee, including the neurological injury compensation
 5455  assessment, are waived for those persons obtaining an expert
 5456  witness certificate. The possession of an expert witness
 5457  certificate alone does not entitle the physician to engage in
 5458  the practice of medicine as defined in s. 458.305.
 5459         (5) The board shall adopt rules to administer this section,
 5460  including rules setting the amount of the expert witness
 5461  certificate application fee, which may not exceed $50. An expert
 5462  witness certificate expires 2 years after the date of issuance.
 5463         Section 67. Subsection (11) is added to section 458.331,
 5464  Florida Statutes, present paragraphs (oo) through (qq) of
 5465  subsection (1) of that section are redesignated as paragraphs
 5466  (pp) through (rr), respectively, and a new paragraph (oo) is
 5467  added to that subsection, to read:
 5468         458.331 Grounds for disciplinary action; action by the
 5469  board and department.—
 5470         (1) The following acts constitute grounds for denial of a
 5471  license or disciplinary action, as specified in s. 456.072(2):
 5472         (oo) Providing misleading, deceptive, or fraudulent expert
 5473  witness testimony related to the practice of medicine.
 5474         (11) The purpose of this section is to facilitate uniform
 5475  discipline for those acts made punishable under this section
 5476  and, to this end, a reference to this section constitutes a
 5477  general reference under the doctrine of incorporation by
 5478  reference.
 5479         Section 68. Section 459.0078, Florida Statutes, is created
 5480  to read:
 5481         459.0078Expert witness certificate.—
 5482         (1) A physician who holds an active and valid license to
 5483  practice osteopathic medicine in any other state or in Canada,
 5484  who submits an application form prescribed by the board to
 5485  obtain a certificate to provide expert testimony and pays the
 5486  application fee, and who has not had a previous expert witness
 5487  certificate revoked by the board shall be issued a certificate
 5488  to provide expert testimony.
 5489         (2) A physician possessing an expert witness certificate
 5490  may use the certificate only to give a verified written medical
 5491  expert opinion as provided in s. 766.203 and to provide expert
 5492  testimony concerning the prevailing professional standard of
 5493  care for medical negligence litigation pending in this state
 5494  against a physician licensed under this chapter or chapter 458.
 5495         (3) An application for an expert witness certificate must
 5496  be approved or denied within 5 business days after receipt of a
 5497  completed application. An application that is not approved or
 5498  denied within the required time period is deemed approved. An
 5499  applicant seeking to claim certification by default shall notify
 5500  the board, in writing, of the intent to rely on the default
 5501  certification provision of this subsection. In such case, s.
 5502  459.013 does not apply, and the applicant may provide expert
 5503  testimony as provided in subsection (2).
 5504         (4) All licensure fees, other than the initial certificate
 5505  application fee, including the neurological injury compensation
 5506  assessment, are waived for those persons obtaining an expert
 5507  witness certificate. The possession of an expert witness
 5508  certificate alone does not entitle the physician to engage in
 5509  the practice of osteopathic medicine as defined in s. 459.003.
 5510         (5) The board shall adopt rules to administer this section,
 5511  including rules setting the amount of the expert witness
 5512  certificate application fee, which may not exceed $50. An expert
 5513  witness certificate expires 2 years after the date of issuance.
 5514         Section 69. Subsection (11) is added to section 459.015,
 5515  Florida Statutes, present paragraphs (qq) through (ss) of
 5516  subsection (1) of that section are redesignated as paragraphs
 5517  (rr) through (tt), respectively, and a new paragraph (qq) is
 5518  added to that subsection, to read:
 5519         459.015 Grounds for disciplinary action; action by the
 5520  board and department.—
 5521         (1) The following acts constitute grounds for denial of a
 5522  license or disciplinary action, as specified in s. 456.072(2):
 5523         (qq) Providing misleading, deceptive, or fraudulent expert
 5524  witness testimony related to the practice of osteopathic
 5525  medicine.
 5526         (11) The purpose of this section is to facilitate uniform
 5527  discipline for those acts made punishable under this section
 5528  and, to this end, a reference to this section constitutes a
 5529  general reference under the doctrine of incorporation by
 5530  reference.
 5531         Section 70. Subsection (23) of section 499.003, Florida
 5532  Statutes, is amended to read:
 5533         499.003 Definitions of terms used in this part.—As used in
 5534  this part, the term:
 5535         (23) “Health care entity” means a closed pharmacy or any
 5536  person, organization, or business entity that provides
 5537  diagnostic, medical, surgical, or dental treatment or care, or
 5538  chronic or rehabilitative care, but does not include any
 5539  wholesale distributor or retail pharmacy licensed under state
 5540  law to deal in prescription drugs. However, a blood
 5541  establishment is a health care entity that may engage in the
 5542  wholesale distribution of prescription drugs under s.
 5543  499.01(2)(g)1.c.
 5544         Section 71. Subsection (21) of section 499.005, Florida
 5545  Statutes, is amended to read:
 5546         499.005 Prohibited acts.—It is unlawful for a person to
 5547  perform or cause the performance of any of the following acts in
 5548  this state:
 5549         (21) The wholesale distribution of any prescription drug
 5550  that was:
 5551         (a) Purchased by a public or private hospital or other
 5552  health care entity; or
 5553         (b) Donated or supplied at a reduced price to a charitable
 5554  organization,
 5555  
 5556  unless the wholesale distribution of the prescription drug is
 5557  authorized in s. 499.01(2)(g)1.c.
 5558         Section 72. Paragraphs (a) and (g) of subsection (2) of
 5559  section 499.01, Florida Statutes, are amended to read:
 5560         499.01 Permits.—
 5561         (2) The following permits are established:
 5562         (a) Prescription drug manufacturer permit.—A prescription
 5563  drug manufacturer permit is required for any person that is a
 5564  manufacturer of a prescription drug and that manufactures or
 5565  distributes such prescription drugs in this state.
 5566         1. A person that operates an establishment permitted as a
 5567  prescription drug manufacturer may engage in wholesale
 5568  distribution of prescription drugs manufactured at that
 5569  establishment and must comply with all of the provisions of this
 5570  part, except s. 499.01212, and the rules adopted under this
 5571  part, except s. 499.01212, which that apply to a wholesale
 5572  distributor.
 5573         2. A prescription drug manufacturer must comply with all
 5574  appropriate state and federal good manufacturing practices.
 5575         3. A blood establishment, as defined in s. 381.06014,
 5576  operating in a manner consistent with the provisions of Title 21
 5577  C.F.R. parts 211 and 600-640 and manufacturing only the
 5578  prescription drugs described in s. 499.003(54)(d) is not
 5579  required to be permitted as a prescription drug manufacturer
 5580  under this paragraph or to register its products under s.
 5581  499.015.
 5582         (g) Restricted prescription drug distributor permit.—
 5583         1. A restricted prescription drug distributor permit is
 5584  required for:
 5585         a. Any person located in this state that engages in the
 5586  distribution of a prescription drug, which distribution is not
 5587  considered “wholesale distribution” under s. 499.003(54)(a).
 5588         b.1.Any A person located in this state who engages in the
 5589  receipt or distribution of a prescription drug in this state for
 5590  the purpose of processing its return or its destruction must
 5591  obtain a permit as a restricted prescription drug distributor if
 5592  such person is not the person initiating the return, the
 5593  prescription drug wholesale supplier of the person initiating
 5594  the return, or the manufacturer of the drug.
 5595         c.A blood establishment located in this state which
 5596  collects blood and blood components only from volunteer donors
 5597  as defined in s. 381.06014 or pursuant to an authorized
 5598  practitioner’s order for medical treatment or therapy and
 5599  engages in the wholesale distribution of a prescription drug not
 5600  described in s. 499.003(54)(d) to a health care entity. The
 5601  health care entity receiving a prescription drug distributed
 5602  under this sub-subparagraph must be licensed as a closed
 5603  pharmacy or provide health care services at that establishment.
 5604  The blood establishment must operate in accordance with s.
 5605  381.06014 and may distribute only:
 5606         (I) Prescription drugs indicated for a bleeding or clotting
 5607  disorder or anemia;
 5608         (II) Blood-collection containers approved under s. 505 of
 5609  the federal act;
 5610         (III) Drugs that are blood derivatives, or a recombinant or
 5611  synthetic form of a blood derivative;
 5612         (IV) Prescription drugs that are identified in rules
 5613  adopted by the department and that are essential to services
 5614  performed or provided by blood establishments and authorized for
 5615  distribution by blood establishments under federal law; or
 5616         (V) To the extent authorized by federal law, drugs
 5617  necessary to collect blood or blood components from volunteer
 5618  blood donors; for blood establishment personnel to perform
 5619  therapeutic procedures under the direction and supervision of a
 5620  licensed physician; and to diagnose, treat, manage, and prevent
 5621  any reaction of either a volunteer blood donor or a patient
 5622  undergoing a therapeutic procedure performed under the direction
 5623  and supervision of a licensed physician,
 5624  
 5625  as long as all of the health care services provided by the blood
 5626  establishment are related to its activities as a registered
 5627  blood establishment or the health care services consist of
 5628  collecting, processing, storing, or administering human
 5629  hematopoietic stem cells or progenitor cells or performing
 5630  diagnostic testing of specimens if such specimens are tested
 5631  together with specimens undergoing routine donor testing.
 5632         2. Storage, handling, and recordkeeping of these
 5633  distributions by a person required to be permitted as a
 5634  restricted prescription drug distributor must comply with the
 5635  requirements for wholesale distributors under s. 499.0121, but
 5636  not those set forth in s. 499.01212 if the distribution occurs
 5637  pursuant to sub-subparagraph 1.a. or sub-subparagraph 1.b.
 5638         3. A person who applies for a permit as a restricted
 5639  prescription drug distributor, or for the renewal of such a
 5640  permit, must provide to the department the information required
 5641  under s. 499.012.
 5642         4. The department may adopt rules regarding the
 5643  distribution of prescription drugs by hospitals, health care
 5644  entities, charitable organizations, or other persons not
 5645  involved in wholesale distribution, and blood establishments,
 5646  which rules are necessary for the protection of the public
 5647  health, safety, and welfare.
 5648         Section 73. Subsection (4) is added to section 626.9541,
 5649  Florida Statutes, to read:
 5650         626.9541 Unfair methods of competition and unfair or
 5651  deceptive acts or practices defined.—
 5652         (4) WELLNESS OR HEALTH IMPROVEMENT PROGRAMS.—
 5653         (a) An insurer issuing a group or individual health benefit
 5654  plan may offer a voluntary wellness or health improvement
 5655  program and may encourage or reward participation in the program
 5656  by authorizing rewards or incentives, including, but not limited
 5657  to, merchandise, gift cards, debit cards, premium discounts or
 5658  rebates, contributions to a member’s health savings account, or
 5659  modifications to copayment, deductible, or coinsurance amounts.
 5660         (b) An insurer may require a health benefit plan member to
 5661  provide verification, such as an affirming statement from the
 5662  member’s physician, that the member’s medical condition makes it
 5663  unreasonably difficult or inadvisable to participate in the
 5664  wellness or health improvement program.
 5665         (c) A reward or incentive offered under this subsection is
 5666  not an insurance benefit or violation of this section if it is
 5667  disclosed in the policy or certificate. This subsection does not
 5668  prohibit insurers from offering other incentives or rewards for
 5669  adherence to a wellness or health improvement program if
 5670  otherwise authorized by state or federal law.
 5671         Section 74. Paragraph (b) of subsection (1) of section
 5672  627.4147, Florida Statutes, is amended to read:
 5673         627.4147 Medical malpractice insurance contracts.—
 5674         (1) In addition to any other requirements imposed by law,
 5675  each self-insurance policy as authorized under s. 627.357 or s.
 5676  624.462 or insurance policy providing coverage for claims
 5677  arising out of the rendering of, or the failure to render,
 5678  medical care or services, including those of the Florida Medical
 5679  Malpractice Joint Underwriting Association, must shall include:
 5680         (b)1.Except as provided in subparagraph 2., a clause
 5681  authorizing the insurer or self-insurer to determine, to make,
 5682  and to conclude, without the permission of the insured, any
 5683  offer of admission of liability and for arbitration pursuant to
 5684  s. 766.106, settlement offer, or offer of judgment, if the offer
 5685  is within the policy limits. It is against public policy for any
 5686  insurance or self-insurance policy to contain a clause giving
 5687  the insured the exclusive right to veto any offer for admission
 5688  of liability and for arbitration made pursuant to s. 766.106,
 5689  settlement offer, or offer of judgment, when such offer is
 5690  within the policy limits. However, any offer of admission of
 5691  liability, settlement offer, or offer of judgment made by an
 5692  insurer or self-insurer shall be made in good faith and in the
 5693  best interests of the insured.
 5694         1.2.a. With respect to dentists licensed under chapter 466,
 5695  a clause clearly stating whether or not the insured has the
 5696  exclusive right to veto any offer of admission of liability and
 5697  for arbitration pursuant to s. 766.106, settlement offer, or
 5698  offer of judgment if the offer is within policy limits. An
 5699  insurer or self-insurer may shall not make or conclude, without
 5700  the permission of the insured, any offer of admission of
 5701  liability and for arbitration pursuant to s. 766.106, settlement
 5702  offer, or offer of judgment, if such offer is outside the policy
 5703  limits. However, any offer for admission of liability and for
 5704  arbitration made under s. 766.106, settlement offer, or offer of
 5705  judgment made by an insurer or self-insurer must shall be made
 5706  in good faith and in the best interest of the insured.
 5707         2.b. If the policy contains a clause stating the insured
 5708  does not have the exclusive right to veto any offer or admission
 5709  of liability and for arbitration made pursuant to s. 766.106,
 5710  settlement offer or offer of judgment, the insurer or self
 5711  insurer shall provide to the insured or the insured’s legal
 5712  representative by certified mail, return receipt requested, a
 5713  copy of the final offer of admission of liability and for
 5714  arbitration made pursuant to s. 766.106, settlement offer or
 5715  offer of judgment and at the same time such offer is provided to
 5716  the claimant. A copy of any final agreement reached between the
 5717  insurer and claimant shall also be provided to the insurer or
 5718  his or her legal representative by certified mail, return
 5719  receipt requested within not more than 10 days after affecting
 5720  such agreement.
 5721         Section 75. Present subsection (12) of section 766.102,
 5722  Florida Statutes, is redesignated as subsection (13), and a new
 5723  subsection (12) is added to that section, to read:
 5724         766.102 Medical negligence; standards of recovery; expert
 5725  witness.—
 5726         (12) If a physician licensed under chapter 458 or chapter
 5727  459 is a party against whom, or on whose behalf, expert
 5728  testimony about the prevailing professional standard of care is
 5729  offered, the expert witness must otherwise meet the requirements
 5730  of this section and be licensed as a physician under chapter 458
 5731  or chapter 459, or must possess a valid expert witness
 5732  certificate issued under s. 458.3167 or s. 459.0078.
 5733         Section 76. Subsection (1) of section 766.104, Florida
 5734  Statutes, is amended to read:
 5735         766.104 Pleading in medical negligence cases; claim for
 5736  punitive damages; authorization for release of records for
 5737  investigation.—
 5738         (1) An No action shall be filed for personal injury or
 5739  wrongful death arising out of medical negligence, whether in
 5740  tort or in contract, may not be filed unless the attorney filing
 5741  the action has made a reasonable investigation, as permitted by
 5742  the circumstances, to determine that there are grounds for a
 5743  good faith belief that there has been negligence in the care or
 5744  treatment of the claimant.
 5745         (a) The complaint or initial pleading must shall contain a
 5746  certificate of counsel that such reasonable investigation gave
 5747  rise to a good faith belief that grounds exist for an action
 5748  against each named defendant. For purposes of this section, good
 5749  faith may be shown to exist if the claimant or his or her
 5750  counsel has received a written opinion, which shall not be
 5751  subject to discovery by an opposing party, of an expert as
 5752  defined in s. 766.102 that there appears to be evidence of
 5753  medical negligence. If the court determines that the such
 5754  certificate of counsel was not made in good faith and that no
 5755  justiciable issue was presented against a health care provider
 5756  that fully cooperated in providing informal discovery, the court
 5757  shall award attorney’s fees and taxable costs against claimant’s
 5758  counsel, and shall submit the matter to The Florida Bar for
 5759  disciplinary review of the attorney.
 5760         (b) If the cause of action requires the plaintiff to
 5761  establish the breach of a standard of care other than negligence
 5762  in order to impose liability or secure specified damages arising
 5763  out of the rendering of, or the failure to render, medical care
 5764  or services, and the plaintiff intends to pursue such liability
 5765  or damages, the investigation and certification required by this
 5766  subsection must demonstrate grounds for a good faith belief that
 5767  the requirement is satisfied.
 5768         Section 77. Subsection (5) of section 766.106, Florida
 5769  Statutes, is amended to read:
 5770         766.106 Notice before filing action for medical negligence;
 5771  presuit screening period; offers for admission of liability and
 5772  for arbitration; informal discovery; review.—
 5773         (5) DISCOVERY AND ADMISSIBILITY.—No statement, discussion,
 5774  written document, report, or other work product generated by the
 5775  presuit screening process is discoverable or admissible in any
 5776  civil action for any purpose by the opposing party. All
 5777  participants, including, but not limited to, physicians,
 5778  investigators, witnesses, and employees or associates of the
 5779  defendant, are immune from civil liability arising from
 5780  participation in the presuit screening process. This subsection
 5781  does not prohibit a physician licensed under chapter 458 or
 5782  chapter 459, or a physician who holds a certificate to provide
 5783  expert testimony under s. 458.3167 or s. 459.0078, who submits a
 5784  verified written expert medical opinion from being subject to
 5785  disciplinary action pursuant to s. 456.073.
 5786         Section 78. Subsection (11) of section 766.1115, Florida
 5787  Statutes, is amended to read:
 5788         766.1115 Health care providers; creation of agency
 5789  relationship with governmental contractors.—
 5790         (11) APPLICABILITY.—
 5791         (a) This section applies to incidents occurring on or after
 5792  April 17, 1992.
 5793         (b) This section does not apply to any health care contract
 5794  entered into by the Department of Corrections which is subject
 5795  to s. 768.28(10)(a).
 5796         (c) This section does not apply to any affiliation
 5797  agreement or other contract subject to s. 768.28(10)(f).
 5798         (d)Nothing in This section does not reduce or limit in any
 5799  way reduces or limits the rights of the state or any of its
 5800  agencies or subdivisions to any benefit currently provided under
 5801  s. 768.28.
 5802         Section 79. Section 766.1183, Florida Statutes, is created
 5803  to read:
 5804         766.1183Standard of care for Medicaid providers.—
 5805         (1) As used in this section:
 5806         (a) The terms “applicant,” “medical assistance,” “medical
 5807  services,” and “Medicaid recipient” have the same meaning as in
 5808  s. 409.901.
 5809         (b) The term “provider” means a health care provider as
 5810  defined in s. 766.202, an ambulance provider licensed under
 5811  chapter 401, or an entity that qualifies for an exemption under
 5812  s. 400.9905(4)(e). The term includes:
 5813         1. Any person or entity for whom a provider is vicariously
 5814  liable; and
 5815         2. Any person or entity whose liability is based solely on
 5816  such person or entity being vicariously liable for the actions
 5817  of a provider.
 5818         (c) The term “wrongful manner” means in bad faith or with
 5819  malicious purpose or in a manner exhibiting wanton and willful
 5820  disregard of human rights, safety, or property, and shall be
 5821  construed in conformity with the standard set forth in s.
 5822  768.28(9)(a).
 5823         (2) A provider is not liable in excess of $200,000 per
 5824  claimant or $300,000 per occurrence for any cause of action
 5825  arising out of the rendering of, or the failure to render,
 5826  medical services to a Medicaid recipient, except as provided
 5827  under subsection (3). However, a judgment may be claimed and
 5828  rendered in excess of the amounts set forth in this subsection.
 5829  That portion of the judgment that exceeds these amounts may be
 5830  reported to the Legislature, but may be paid in part or in whole
 5831  by the state only by further act of the Legislature.
 5832         (3) A provider may be liable for an amount in excess of
 5833  $200,000 per claimant or $300,000 per occurrence only if the
 5834  claimant pleads and proves, by clear and convincing evidence,
 5835  that the provider acted in a wrongful manner. If the claimant so
 5836  pleads, the court, after a reasonable opportunity for discovery,
 5837  shall conduct a hearing before trial to determine if there is a
 5838  reasonable basis in evidence to conclude that the provider acted
 5839  in a wrongful manner. A claim for wrongful conduct is not
 5840  permitted, to the extent it exceeds the amounts set forth in
 5841  subsection (2), unless the claimant makes the showing required
 5842  by this subsection.
 5843         (4) At the time an application for medical assistance is
 5844  submitted, the Department of Children and Family Services shall
 5845  furnish the applicant with written notice of the provisions of
 5846  this section.
 5847         (5) This section does not limit or exclude the application
 5848  of any law, including s. 766.118, which places limitations upon
 5849  the recovery of civil damages.
 5850         (6) This section does not apply to any claim for damages to
 5851  which s. 768.28 applies.
 5852         Section 80. Section 766.1184, Florida Statutes, is created
 5853  to read:
 5854         766.1184Standard of care; low-income pool recipient.—
 5855         (1) As used in this section, the term:
 5856         (a) “Low-income pool recipient” means a low-income
 5857  individual who is uninsured or underinsured and who receives
 5858  primary care services from a provider which are delivered
 5859  exclusively using funding received by that provider under
 5860  proviso language accompanying specific appropriation 191 of the
 5861  2010-2011 fiscal year General Appropriations Act to establish
 5862  new or expand existing primary care clinics for low-income
 5863  persons who are uninsured or underinsured.
 5864         (b) “Provider” means a health care provider, as defined in
 5865  s. 766.202, which received funding under proviso language
 5866  accompanying specific appropriation 191 of the fiscal year 2010
 5867  11 General Appropriations Act to establish new or expand
 5868  existing primary care clinics for low-income persons who are
 5869  uninsured or underinsured. The term includes:
 5870         1. Any person or entity for whom a provider is vicariously
 5871  liable; and
 5872         2. Any person or entity whose liability is based solely on
 5873  such person or entity being vicariously liable for the actions
 5874  of a provider.
 5875         (c) “Wrongful manner” means in bad faith or with malicious
 5876  purpose or in a manner exhibiting wanton and willful disregard
 5877  of human rights, safety, or property, and shall be construed in
 5878  conformity with the standard set forth in s. 768.28(9)(a).
 5879  
 5880  The funding of the provider’s primary care clinic must have been
 5881  awarded pursuant to a plan approved by the Legislative Budget
 5882  Commission, and must be the subject of an agreement between the
 5883  provider and the Agency for Health Care Administration,
 5884  following the competitive solicitation of proposals to use low
 5885  income pool grant funds to provide primary care services in
 5886  general acute hospitals, county health departments, faith-based
 5887  and community clinics, and federally qualified health centers to
 5888  uninsured or underinsured persons.
 5889         (2) A provider is not liable in excess of $200,000 per
 5890  claimant or $300,000 per occurrence for any cause of action
 5891  arising out of the rendering of, or the failure to render,
 5892  primary care services to a low-income pool recipient, except as
 5893  provided under subsection (3). However, a judgment may be
 5894  claimed and rendered in excess of the amounts set forth in this
 5895  subsection. That portion of the judgment that exceeds these
 5896  amounts may be reported to the Legislature, but may be paid in
 5897  part or in whole by the state only by further act of the
 5898  Legislature.
 5899         (3) A provider may be liable for an amount in excess of
 5900  $200,000 per claimant or $300,000 per occurrence only if the
 5901  claimant pleads and proves, by clear and convincing evidence,
 5902  that the provider acted in a wrongful manner. If the claimant so
 5903  pleads, the court, after a reasonable opportunity for discovery,
 5904  shall conduct a hearing before trial to determine if there is a
 5905  reasonable basis in evidence to conclude that the provider acted
 5906  in a wrongful manner. A claim for wrongful conduct is not
 5907  permitted, to the extent it exceeds the amounts set forth in
 5908  subsection (2), unless the claimant makes the showing required
 5909  by this subsection.
 5910         (4) In order for this section to apply, the provider must:
 5911         (a) Develop, implement, and maintain policies and
 5912  procedures to:
 5913         1. Ensure that funds described in subsection (1) are used
 5914  exclusively to serve low-income persons who are uninsured or
 5915  underinsured;
 5916         2. Determine whether funds described in subsection (1) are
 5917  being used to provide primary care services to a particular
 5918  person; and
 5919         3. Identify whether an individual receiving primary care
 5920  services is a low-income pool recipient to whom the provisions
 5921  of this section apply.
 5922         (b) Furnish a low-income pool recipient with written notice
 5923  of the provisions of this section before providing primary care
 5924  services to the recipient.
 5925         (c) Be in compliance with the terms of any agreement
 5926  between the provider and the Agency for Health Care
 5927  Administration governing the receipt of the funds described in
 5928  subsection (1).
 5929         (5) This section does not limit or exclude the application
 5930  of any law, including s. 766.118, which places limitations upon
 5931  the recovery of civil damages.
 5932         (6) This section does not apply to any claim for damages to
 5933  which s. 768.28 applies.
 5934         Section 81. Subsection (5) is added to section 766.203,
 5935  Florida Statutes, to read:
 5936         766.203 Presuit investigation of medical negligence claims
 5937  and defenses by prospective parties.—
 5938         (5) STANDARDS OF CARE.—If the cause of action that is the
 5939  basis for the litigation requires the plaintiff to establish the
 5940  breach of a standard of care other than negligence in order to
 5941  impose liability or secure specified damages arising out of the
 5942  rendering of, or the failure to render, medical care or
 5943  services, and the plaintiff intends to pursue such liability or
 5944  damages, the presuit investigations required of the claimant and
 5945  the prospective defendant by this section must ascertain that
 5946  there are reasonable grounds to believe that the requirement is
 5947  satisfied.
 5948         Section 82. Paragraph (b) of subsection (9) of section
 5949  768.28, Florida Statutes, is amended, and paragraphs (f) and (g)
 5950  are added to subsection (10) of that section, to read:
 5951         768.28 Waiver of sovereign immunity in tort actions;
 5952  recovery limits; limitation on attorney fees; statute of
 5953  limitations; exclusions; indemnification; risk management
 5954  programs.—
 5955         (9)
 5956         (b) As used in this subsection, the term:
 5957         1. “Employee” includes any volunteer firefighter.
 5958         2. “Officer, employee, or agent” includes, but is not
 5959  limited to, any health care provider when providing services
 5960  pursuant to s. 766.1115;, any member of the Florida Health
 5961  Services Corps, as defined in s. 381.0302, who provides
 5962  uncompensated care to medically indigent persons referred by the
 5963  Department of Health; any nonprofit independent college or
 5964  university located and chartered in this state which owns or
 5965  operates an accredited medical school, and its employees or
 5966  agents, when providing patient services pursuant to paragraph
 5967  (10)(f);, and any public defender or her or his employee or
 5968  agent, including, among others, an assistant public defender and
 5969  an investigator.
 5970         (10)
 5971         (f) For purposes of this section, any nonprofit independent
 5972  college or university located and chartered in this state which
 5973  owns or operates an accredited medical school, or any of its
 5974  employees or agents, and which has agreed in an affiliation
 5975  agreement or other contract to provide, or to permit its
 5976  employees or agents to provide, patient services as agents of a
 5977  teaching hospital, is considered an agent of the teaching
 5978  hospital while acting within the scope of and pursuant to
 5979  guidelines established in the contract. To the extent allowed by
 5980  law, the contract must provide for the indemnification of the
 5981  state, up to the limits set out in this chapter, by the agent
 5982  for any liability incurred which was caused by the negligence of
 5983  the college or university or its employees or agents.
 5984         1. For purposes of this paragraph, the term:
 5985         a. “Employee or agent” means an officer, employee, agent,
 5986  or servant of a nonprofit independent college or university
 5987  located and chartered in this state which owns or operates an
 5988  accredited medical school, including, but not limited to, the
 5989  faculty of the medical school, any health care practitioner or
 5990  licensee as defined in s. 456.001 for which the college or
 5991  university is vicariously liable, and the staff or administrator
 5992  of the medical school.
 5993         b. “Patient services” mean:
 5994         (I) Comprehensive health care services as defined in s.
 5995  641.19, including any related administrative service, provided
 5996  to patients in a teaching hospital or in a health care facility
 5997  that is a part of a nonprofit independent college or university
 5998  located and chartered in this state which owns or operates an
 5999  accredited medical school, pursuant to an affiliation agreement
 6000  or other contract with a teaching hospital;
 6001         (II) Training and supervision of interns, residents, and
 6002  fellows providing patient services in a teaching hospital or in
 6003  a health care facility that is a part of a nonprofit independent
 6004  college or university located and chartered in this state which
 6005  owns or operates an accredited medical school, pursuant to an
 6006  affiliation agreement or other contract with a teaching
 6007  hospital;
 6008         (III) Participation in medical research protocols; or
 6009         (IV) Training and supervision of medical students in a
 6010  teaching hospital or in a health care facility owned by a not
 6011  for-profit college or university that owns or operates an
 6012  accredited medical school, pursuant to an affiliation agreement
 6013  or other contract with a teaching hospital.
 6014         c. “Teaching hospital” means a teaching hospital as defined
 6015  in s. 408.07 which is owned or operated by the state, a county
 6016  or municipality, a public health trust, a special taxing
 6017  district, a governmental entity having health care
 6018  responsibilities, or a not-for-profit entity that operates such
 6019  facilities as an agent of the state or a political subdivision
 6020  of the state under a lease or other contract.
 6021         2. The teaching hospital or the medical school, or its
 6022  employees or agents, must provide written notice to each
 6023  patient, or the patient’s legal representative, receipt of which
 6024  must be acknowledged in writing, that the college or university
 6025  that owns or operates the medical school and the employees or
 6026  agents of that college or university are acting as agents of the
 6027  teaching hospital and that the exclusive remedy for injury or
 6028  damage suffered as the result of any act or omission of the
 6029  teaching hospital, the college or university that owns or
 6030  operates the medical school, or the employees or agents of the
 6031  college or university while acting within the scope of duties
 6032  pursuant to the affiliation agreement or other contract with a
 6033  teaching hospital, is by commencement of an action pursuant to
 6034  the provisions of this section.
 6035         3. This paragraph does not designate any employee providing
 6036  contracted patient services in a teaching hospital as an
 6037  employee or agent of the state for purposes of chapter 440.
 6038         (g) Providers or vendors, 75 percent of whose client
 6039  population consists of individuals with a developmental
 6040  disability as defined in ss. 393.063 and 400.960, individuals
 6041  who are blind or severely handicapped individuals as defined in
 6042  s. 413.033, individuals who have a mental illness as defined
 6043  under s. 394.455, or individuals who have any combination of
 6044  these conditions, which have contractually agreed to act on
 6045  behalf of the Agency for Persons with Disabilities, the Agency
 6046  for Health Care Administration, the Division of Blind Services
 6047  in the Department of Education, or the Mental Health Program
 6048  Office of the Department of Children and Family Services to
 6049  provide services to such individuals, and their employees or
 6050  agents, are considered agents of the state, solely with respect
 6051  to the provision of such services while acting within the scope
 6052  of and pursuant to guidelines established by contract, a
 6053  Medicaid waiver agreement, or rule. The contracts for such
 6054  services must provide for the indemnification of the state by
 6055  the agent for any liabilities incurred up to the limits
 6056  specified in this section.
 6057         Section 83. Legislative findings and intent.
 6058         (1) The Legislature finds that:
 6059         (a) Access to high-quality, comprehensive, and affordable
 6060  health care for all persons in this state is a necessary state
 6061  goal and that teaching hospitals play an intrinsic and essential
 6062  role in providing that access.
 6063         (b) Graduate medical education, provided by nonprofit
 6064  independent colleges and universities located and chartered in
 6065  this state which own or operate medical schools, helps provide
 6066  the comprehensive specialty training needed by medical school
 6067  graduates to develop and refine the skills essential to the
 6068  provision of high-quality health care for our state residents.
 6069  Much of that education and training is provided in teaching
 6070  hospitals under the direct supervision of medical faculty who
 6071  provide guidance, training, and oversight, and serve as role
 6072  models to their students.
 6073         (c) A large proportion of medical care is provided in
 6074  teaching hospitals that serve as safety nets for many indigent
 6075  and underserved patients who otherwise might not receive the
 6076  medical help they need. Resident physician training that takes
 6077  place in such hospitals provides much of the care provided to
 6078  this population. Medical faculty, supervising such training and
 6079  care, are a vital link between educating and training resident
 6080  physicians and ensuring the provision of quality care for
 6081  indigent and underserved residents. Physicians that assume this
 6082  role are often called upon to juggle the demands of patient
 6083  care, teaching, research, health policy, and budgetary issues
 6084  related to the programs they administer.
 6085         (d) While teaching hospitals are afforded sovereign
 6086  immunity protections under s. 768.28, Florida Statutes, the
 6087  nonprofit independent colleges and universities located and
 6088  chartered in this state which own or operate medical schools and
 6089  which enter into affiliation agreements or contracts with the
 6090  teaching hospitals to provide patient services are not afforded
 6091  such sovereign immunity protections.
 6092         (e) The employees or agents of nonprofit independent
 6093  colleges and universities located and chartered in this state
 6094  which enter into affiliation agreements or contracts with
 6095  teaching hospitals to provide patient services do not have the
 6096  same level of protection against liability claims as teaching
 6097  hospitals and their employees and agents that provide the same
 6098  patient services to the same patients. Thus, these colleges and
 6099  universities and their employees and agents are
 6100  disproportionately affected by claims arising out of alleged
 6101  medical malpractice and other allegedly negligent acts. Given
 6102  the recent growth in medical schools and medical education
 6103  programs and ongoing efforts to support, strengthen, and
 6104  increase physician residency training positions and medical
 6105  faculty in both existing and newly designated teaching
 6106  hospitals, this exposure and the consequent disparity in
 6107  liability exposure will continue to increase. The vulnerability
 6108  of these colleges and universities to claims of medical
 6109  malpractice will only add to the current physician workforce
 6110  crisis in Florida and can be alleviated only through legislative
 6111  action.
 6112         (f) Ensuring that the employees and agents of nonprofit
 6113  independent colleges and universities located and chartered in
 6114  this state which own or operated medical schools are able to
 6115  continue to treat patients, provide graduate medical education,
 6116  supervise medical students, engage in research, and provide
 6117  administrative support and services in teaching hospitals is an
 6118  overwhelming public necessity.
 6119         (2) The Legislature intends that:
 6120         (a) Employees and agents of nonprofit independent colleges
 6121  and universities located and chartered in this state which own
 6122  or operate medical schools, who provide patient services as
 6123  agents of a teaching hospital be immune from lawsuits in the
 6124  same manner and to the same extent as employees and agents of
 6125  teaching hospitals in this state under existing law, and that
 6126  such colleges and universities and their employees and agents
 6127  not be held personally liable in tort or named as a party
 6128  defendant in an action while providing patient services in a
 6129  teaching hospital, unless such services are provided in bad
 6130  faith, with malicious purpose, or in a manner exhibiting wanton
 6131  and willful disregard of human rights, safety, or property.
 6132         (b) Nonprofit independent private colleges and universities
 6133  located and chartered in this state which own or operate medical
 6134  schools and which permit their employees or agents to provide
 6135  patient services in teaching hospitals pursuant to an
 6136  affiliation agreement or other contract, be afforded sovereign
 6137  immunity protections under s. 768.28, Florida Statutes.
 6138         (3) The Legislature declares that there is an overwhelming
 6139  public necessity for extending the state’s sovereign immunity to
 6140  nonprofit independent colleges and universities located and
 6141  chartered in this state which own or operate medical schools and
 6142  provide patient services in teaching hospitals, and to their
 6143  employees and agents, and that there is no alternative method of
 6144  meeting such public necessity.
 6145         (4) The terms “employee or agent,” “patient services,” and
 6146  “teaching hospital” used in this section have the same meaning
 6147  as the terms defined in s. 768.28, Florida Statutes, as amended
 6148  by this act.
 6149         Section 84. Section 1004.41, Florida Statutes, is amended
 6150  to read:
 6151         1004.41 University of Florida; J. Hillis Miller Health
 6152  Center.—
 6153         (1) There is established the J. Hillis Miller Health Center
 6154  at the University of Florida, including campuses at Gainesville
 6155  and Jacksonville and affiliated teaching hospitals, which shall
 6156  include the following colleges:
 6157         (a) College of Dentistry.
 6158         (b) College of Public Health and Health Professions.
 6159         (c) College of Medicine.
 6160         (d) College of Nursing.
 6161         (e) College of Pharmacy.
 6162         (f) College of Veterinary Medicine and related teaching
 6163  hospitals.
 6164         (2) Each college of the health center shall be so
 6165  maintained and operated so as to comply with the standards
 6166  approved by a nationally recognized association for
 6167  accreditation.
 6168         (3)(a) The University of Florida Health Center Operations
 6169  and Maintenance Trust Fund shall be administered by the
 6170  University of Florida Board of Trustees. Funds shall be credited
 6171  to the trust fund from the sale of goods and services performed
 6172  by the University of Florida Veterinary Medicine Teaching
 6173  Hospital. The purpose of the trust fund is to support the
 6174  instruction, research, and service missions of the University of
 6175  Florida College of Veterinary Medicine.
 6176         (b) Notwithstanding the provisions of s. 216.301, and
 6177  pursuant to s. 216.351, any balance in the trust fund at the end
 6178  of any fiscal year shall remain in the trust fund and shall be
 6179  available for carrying out the purposes of the trust fund.
 6180         (4)(a) The University of Florida Board of Trustees shall
 6181  lease the hospital facilities of the health center known as the
 6182  Shands Teaching Hospital and Clinics on the Gainesville campus
 6183  of the University of Florida and all furnishings, equipment, and
 6184  other chattels or choses in action used in the operation of the
 6185  hospital, to Shands Teaching Hospital and Clinics, Inc., a
 6186  private not-for-profit corporation organized solely for the
 6187  primary purpose of supporting operating the University of
 6188  Florida Board of Trustees’ health affairs mission of community
 6189  service and patient care, education and training of health
 6190  professionals, and clinical research. In furtherance of that
 6191  purpose, Shands Teaching Hospital and Clinics, Inc., shall
 6192  operate the hospital and ancillary health care facilities as
 6193  deemed of the health center and other health care facilities and
 6194  programs determined to be necessary by the board of Shands
 6195  Teaching Hospital and Clinics, Inc. the nonprofit corporation.
 6196  The rental for the hospital facilities shall be an amount equal
 6197  to the debt service on bonds or revenue certificates issued
 6198  solely for capital improvements to the hospital facilities or as
 6199  otherwise provided by law.
 6200         (b) The University of Florida Board of Trustees shall
 6201  provide in the lease or by separate contract or agreement with
 6202  Shands Teaching Hospital and Clinics, Inc., the not-for-profit
 6203  corporation for the following:
 6204         1. Approval of the articles of incorporation of Shands
 6205  Teaching Hospital and Clinics, Inc., the not-for-profit
 6206  corporation by the University of Florida Board of Trustees and
 6207  the governance of that the not-for-profit corporation by a board
 6208  of directors appointed, subject to removal, and chaired by the
 6209  President of the University of Florida, or his or her designee,
 6210  and vice chaired by the Vice President for Health Affairs of the
 6211  University of Florida, or his or her designee.
 6212         2. The use of hospital facilities and personnel in support
 6213  of community service and patient care, the research programs,
 6214  and of the teaching roles role of the health center.
 6215         3. The continued recognition of the collective bargaining
 6216  units and collective bargaining agreements as currently composed
 6217  and recognition of the certified labor organizations
 6218  representing those units and agreements.
 6219         4. The use of hospital facilities and personnel in
 6220  connection with research programs conducted by the health
 6221  center.
 6222         5. Reimbursement to the hospital for indigent patients,
 6223  state-mandated programs, underfunded state programs, and costs
 6224  to the hospital for support of the teaching and research
 6225  programs of the health center. Such reimbursement shall be
 6226  appropriated to either the health center or the hospital each
 6227  year by the Legislature after review and approval of the request
 6228  for funds.
 6229         (c) The University of Florida Board of Trustees may, with
 6230  the approval of the Legislature, increase the hospital
 6231  facilities or remodel or renovate them, provided that the rental
 6232  paid by the hospital for such new, remodeled, or renovated
 6233  facilities is sufficient to amortize the costs thereof over a
 6234  reasonable period of time or fund the debt service for any bonds
 6235  or revenue certificates issued to finance such improvements.
 6236         (d) The University of Florida Board of Trustees is
 6237  authorized to provide to Shands Teaching Hospital and Clinics,
 6238  Inc., the not-for-profit corporation leasing the hospital
 6239  facilities and its not-for-profit subsidiaries and affiliates
 6240  comprehensive general liability insurance including professional
 6241  liability from a self-insurance trust program established
 6242  pursuant to s. 1004.24.
 6243         (e)Shands Teaching Hospital and Clinics, Inc., may, in
 6244  support of the health affairs mission of the University of
 6245  Florida Board of Trustees and with its prior approval, create
 6246  for-profit or not-for-profit corporate subsidiaries and
 6247  affiliates, or both. The University of Florida Board of
 6248  Trustees, which may act through the President of the University
 6249  of Florida or his or her designee, has the right to control
 6250  Shands Teaching Hospital and Clinics, Inc. Shands Teaching
 6251  Hospital and Clinics, Inc., and any not-for-profit subsidiaries
 6252  are conclusively deemed corporations primarily acting as
 6253  instrumentalities of the state, pursuant to s. 768.28(2), for
 6254  purposes of sovereign immunity.
 6255         (f)(e)If In the event that the lease of the hospital
 6256  facilities to Shands Teaching Hospital and Clinics, Inc., the
 6257  not-for-profit corporation is terminated for any reason, the
 6258  University of Florida Board of Trustees shall resume management
 6259  and operation of the hospital facilities. In such event, the
 6260  University of Florida Board of Trustees is authorized to utilize
 6261  revenues generated from the operation of the hospital facilities
 6262  to pay the costs and expenses of operating the hospital facility
 6263  for the remainder of the fiscal year in which such termination
 6264  occurs.
 6265         (5)(f)Shands Jacksonville Medical Center, Inc., and its
 6266  parent Shands Jacksonville Healthcare, Inc., are private not
 6267  for-profit corporations organized primarily to support the
 6268  health affairs mission of the University of Florida Board of
 6269  Trustees in community service and patient care, education and
 6270  training of health affairs professionals, and clinical research.
 6271  Shands Jacksonville Medical Center, Inc., is a teaching hospital
 6272  affiliated with the University of Florida Board of Trustees,
 6273  located on the Jacksonville Campus of the University of Florida.
 6274  Shands Jacksonville Medical Center, Inc., and Shands
 6275  Jacksonville Healthcare, Inc., may, in support of the health
 6276  affairs mission of the University of Florida Board of Trustees
 6277  and with its prior approval, create for-profit or not-for-profit
 6278  corporate subsidiaries and affiliates, or both.
 6279         (a) The University of Florida Board of Trustees, which may
 6280  act through the President of the University of Florida or his or
 6281  her designee, has the right to control Shands Jacksonville
 6282  Medical Center, Inc., and Shands Jacksonville Healthcare, Inc.
 6283  Shands Jacksonville Medical Center, Inc., Shands Jacksonville
 6284  Healthcare, Inc., and any not-for-profit subsidiary of Shands
 6285  Jacksonville Medical Center, Inc., are conclusively deemed
 6286  corporations primarily acting as instrumentalities of the state,
 6287  pursuant to s. 768.28(2), for purposes of sovereign immunity.
 6288         (b) The University of Florida Board of Trustees is
 6289  authorized to provide to Shands Jacksonville Healthcare, Inc.,
 6290  and its not-for-profit subsidiaries and affiliates and any
 6291  successor corporation that acts in support of the board of
 6292  trustees, comprehensive general liability coverage, including
 6293  professional liability, from the self-insurance programs
 6294  established pursuant to s. 1004.24.
 6295         Section 85. Sections 409.9121, 409.919, and 624.915,
 6296  Florida Statutes, are repealed.
 6297         Section 86. Section 409.942, Florida Statutes, is
 6298  transferred and renumbered as section 414.29, Florida Statutes.
 6299         Section 87. Paragraph (a) of subsection (1) of section
 6300  443.111, Florida Statutes, is amended to read:
 6301         443.111 Payment of benefits.—
 6302         (1) MANNER OF PAYMENT.—Benefits are payable from the fund
 6303  in accordance with rules adopted by the Agency for Workforce
 6304  Innovation, subject to the following requirements:
 6305         (a) Benefits are payable by mail or electronically.
 6306  Notwithstanding s. 414.29 409.942(4), the agency may develop a
 6307  system for the payment of benefits by electronic funds transfer,
 6308  including, but not limited to, debit cards, electronic payment
 6309  cards, or any other means of electronic payment that the agency
 6310  deems to be commercially viable or cost-effective. Commodities
 6311  or services related to the development of such a system shall be
 6312  procured by competitive solicitation, unless they are purchased
 6313  from a state term contract pursuant to s. 287.056. The agency
 6314  shall adopt rules necessary to administer the system.
 6315         Section 88. Sections 409.944, 409.945, and 409.946, Florida
 6316  Statutes, are transferred and renumbered as sections 163.464,
 6317  163.465, and 163.466, Florida Statutes, respectively.
 6318         Section 89. Sections 409.953 and 409.9531, Florida
 6319  Statutes, are transferred and renumbered as sections 402.81 and
 6320  402.82, Florida Statutes, respectively.
 6321         Section 90. The Agency for Health Care Administration shall
 6322  submit a reorganizational plan to the Governor, the Speaker of
 6323  the House of Representatives, and the President of the Senate by
 6324  January 1, 2012, which converts the agency from a check-writing
 6325  and fraud-chasing agency into a contract compliance and
 6326  monitoring agency.
 6327         Section 91. Effective December 1, 2011, if the Legislature
 6328  has not received a letter from the Governor stating that the
 6329  federal Centers for Medicare and Medicaid has approved the
 6330  waivers necessary to implement the Medicaid managed care reforms
 6331  contained in this act, the State of Florida shall withdraw from
 6332  the Medicaid program effective December 31, 2011.
 6333         Section 92. If any provision of this act or its application
 6334  to any person or circumstance is held invalid, the invalidity
 6335  does not affect other provisions or applications of the act
 6336  which can be given effect without the invalid provision or
 6337  application, and to this end the provisions of this act are
 6338  severable.
 6339         Section 93. This act shall take effect upon becoming a law.