Florida Senate - 2016 SENATOR AMENDMENT
Bill No. HB 5101
Ì3904640Î390464
LEGISLATIVE ACTION
Senate . House
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Floor: 1/R/CR .
03/11/2016 05:31 PM .
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Senator Garcia moved the following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Subsection (2) of section 322.143, Florida
6 Statutes, is amended and subsection (10) is added to that
7 section, to read:
8 322.143 Use of a driver license or identification card.—
9 (2) Except as provided in subsections (6) and (10)
10 subsection (6), a private entity may not swipe an individual’s
11 driver license or identification card, except for the following
12 purposes:
13 (a) To verify the authenticity of a driver license or
14 identification card or to verify the identity of the individual
15 if the individual pays for a good or service with a method other
16 than cash, returns an item, or requests a refund.
17 (b) To verify the individual’s age when providing an age
18 restricted good or service.
19 (c) To prevent fraud or other criminal activity if an
20 individual returns an item or requests a refund and the private
21 entity uses a fraud prevention service company or system.
22 (d) To transmit information to a check services company for
23 the purpose of approving negotiable instruments, electronic
24 funds transfers, or similar methods of payment.
25 (e) To comply with a legal requirement to record, retain,
26 or transmit the driver license information.
27 (10) To combat health care fraud, the Department of Highway
28 Safety and Motor Vehicles shall provide photographic access,
29 pursuant to a written agreement, with hospitals, insurance
30 companies, or their software providers, for the purpose of
31 verifying a patient’s identity or Medicaid eligibility by
32 swiping an individual’s driver license or identification card.
33 Section 2. Paragraph (e) of subsection (2) of section
34 395.602, Florida Statutes, is amended to read:
35 395.602 Rural hospitals.—
36 (2) DEFINITIONS.—As used in this part, the term:
37 (e) “Rural hospital” means an acute care hospital licensed
38 under this chapter, having 100 or fewer licensed beds and an
39 emergency room, which is:
40 1. The sole provider within a county with a population
41 density of up to 100 persons per square mile;
42 2. An acute care hospital, in a county with a population
43 density of up to 100 persons per square mile, which is at least
44 30 minutes of travel time, on normally traveled roads under
45 normal traffic conditions, from any other acute care hospital
46 within the same county;
47 3. A hospital supported by a tax district or subdistrict
48 whose boundaries encompass a population of up to 100 persons per
49 square mile;
50 4. A hospital classified as a sole community hospital under
51 42 C.F.R. s. 412.92 which has up to 175 licensed beds.
52 5.4. A hospital with a service area that has a population
53 of up to 100 persons per square mile. As used in this
54 subparagraph, the term “service area” means the fewest number of
55 zip codes that account for 75 percent of the hospital’s
56 discharges for the most recent 5-year period, based on
57 information available from the hospital inpatient discharge
58 database in the Florida Center for Health Information and Policy
59 Analysis at the agency; or
60 6.5. A hospital designated as a critical access hospital,
61 as defined in s. 408.07.
62
63 Population densities used in this paragraph must be based upon
64 the most recently completed United States census. A hospital
65 that received funds under s. 409.9116 for a quarter beginning no
66 later than July 1, 2002, is deemed to have been and shall
67 continue to be a rural hospital from that date through June 30,
68 2021, if the hospital continues to have up to 100 licensed beds
69 and an emergency room. An acute care hospital that has not
70 previously been designated as a rural hospital and that meets
71 the criteria of this paragraph shall be granted such designation
72 upon application, including supporting documentation, to the
73 agency. A hospital that was licensed as a rural hospital during
74 the 2010-2011 or 2011-2012 fiscal year shall continue to be a
75 rural hospital from the date of designation through June 30,
76 2021, if the hospital continues to have up to 100 licensed beds
77 and an emergency room.
78 Section 3. Section 409.285, Florida Statutes, is amended to
79 read:
80 409.285 Opportunity for hearing and appeal.—
81 (1) If an application for public assistance is not acted
82 upon within a reasonable time after the filing of the
83 application, or is denied in whole or in part, or if an
84 assistance payment is modified or canceled, the applicant or
85 recipient may appeal the decision to the Department of Children
86 and Families in the manner and form prescribed by the
87 department.
88 (a)(2) The hearing authority may be the Secretary of
89 Children and Families, a panel of department officials, or a
90 hearing officer appointed for that purpose. The hearing
91 authority is responsible for a final administrative decision in
92 the name of the department on all issues that have been the
93 subject of a hearing. With regard to the department, the
94 decision of the hearing authority is final and binding. The
95 department is responsible for seeing that the decision is
96 carried out promptly.
97 (b)(3) The department may adopt rules to administer this
98 subsection section. Rules for the Temporary Assistance for Needy
99 Families block grant programs must be similar to the federal
100 requirements for Medicaid programs.
101 (2) Appeals related to Medicaid programs directly
102 administered by the Agency for Health Care Administration,
103 including appeals related to Florida’s Statewide Medicaid
104 Managed Care program and associated federal waivers, must be
105 directed to the Agency for Health Care Administration in the
106 manner and form prescribed by the agency.
107 (a) The hearing authority for appeals heard by the Agency
108 for Health Care Administration may be the secretary of the
109 agency, a panel of agency officials, or a hearing officer
110 appointed for that purpose. The hearing authority is responsible
111 for a final administrative decision in the name of the agency on
112 all issues that have been the subject of a hearing. A decision
113 of the hearing authority is final and binding on the agency. The
114 agency is responsible for seeing that the decision is promptly
115 carried out.
116 (b) Notwithstanding ss. 120.569 and 120.57, hearings
117 conducted by the Agency for Health Care Administration pursuant
118 to this subsection are exempt from the uniform rules of
119 procedure under s. 120.54(5) and do not need to be conducted by
120 an administrative law judge assigned by the Division of
121 Administrative Hearings.
122 (c) The Agency for Health Care Administration shall seek
123 federal approval necessary to implement this subsection and may
124 adopt rules necessary to administer this subsection.
125 (3) Appeals related to Medicaid programs administered by
126 the Agency for Persons with Disabilities are subject to s.
127 393.125.
128 Section 4. Present subsections (17) through (22) of section
129 409.811, Florida Statutes, are redesignated as subsections (18)
130 through (23), respectively, a new subsection (17) is added to
131 that section, and present subsections (23) and (24) of that
132 section are amended, to read:
133 409.811 Definitions relating to Florida Kidcare Act.—As
134 used in ss. 409.810-409.821, the term:
135 (17) “Lawfully residing child” means a child who is
136 lawfully present in the United States, meets Medicaid or
137 Children’s Health Insurance Program (CHIP) residency
138 requirements, and may be eligible for medical assistance with
139 federal financial participation as provided under s. 214 of the
140 Children’s Health Insurance Program Reauthorization Act of 2009,
141 Pub. L. No. 111-3, and related federal regulations.
142 (23) “Qualified alien” means an alien as defined in s. 431
143 of the Personal Responsibility and Work Opportunity
144 Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
145 (24) “Resident” means a United States citizen, or lawfully
146 residing child qualified alien, who is domiciled in this state.
147 Section 5. Paragraph (c) of subsection (4) of section
148 409.814, Florida Statutes, is amended to read:
149 409.814 Eligibility.—A child who has not reached 19 years
150 of age whose family income is equal to or below 200 percent of
151 the federal poverty level is eligible for the Florida Kidcare
152 program as provided in this section. If an enrolled individual
153 is determined to be ineligible for coverage, he or she must be
154 immediately disenrolled from the respective Florida Kidcare
155 program component.
156 (4) The following children are not eligible to receive
157 Title XXI-funded premium assistance for health benefits coverage
158 under the Florida Kidcare program, except under Medicaid if the
159 child would have been eligible for Medicaid under s. 409.903 or
160 s. 409.904 as of June 1, 1997:
161 (c) A child who is an alien, but who does not meet the
162 definition of a lawfully residing child qualified alien, in the
163 United States. This paragraph does not extend eligibility for
164 the Florida Kidcare program to an undocumented immigrant.
165 Section 6. Present subsections (8) and (9) of section
166 409.904, Florida Statutes, are redesignated as subsections (9)
167 and (10), respectively, and a new subsection (8) is added to
168 that section, to read:
169 409.904 Optional payments for eligible persons.—The agency
170 may make payments for medical assistance and related services on
171 behalf of the following persons who are determined to be
172 eligible subject to the income, assets, and categorical
173 eligibility tests set forth in federal and state law. Payment on
174 behalf of these Medicaid eligible persons is subject to the
175 availability of moneys and any limitations established by the
176 General Appropriations Act or chapter 216.
177 (8) A child who has not attained 19 years of age and who,
178 notwithstanding s. 414.095(3), would be eligible for Medicaid
179 under s. 409.903, except that the child is a lawfully residing
180 child as defined in s. 409.811. This subsection does not extend
181 eligibility for optional Medicaid payments or related services
182 to an undocumented immigrant.
183 Section 7. Subsection (5) of section 409.905, Florida
184 Statutes, is amended to read:
185 409.905 Mandatory Medicaid services.—The agency may make
186 payments for the following services, which are required of the
187 state by Title XIX of the Social Security Act, furnished by
188 Medicaid providers to recipients who are determined to be
189 eligible on the dates on which the services were provided. Any
190 service under this section shall be provided only when medically
191 necessary and in accordance with state and federal law.
192 Mandatory services rendered by providers in mobile units to
193 Medicaid recipients may be restricted by the agency. Nothing in
194 this section shall be construed to prevent or limit the agency
195 from adjusting fees, reimbursement rates, lengths of stay,
196 number of visits, number of services, or any other adjustments
197 necessary to comply with the availability of moneys and any
198 limitations or directions provided for in the General
199 Appropriations Act or chapter 216.
200 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
201 all covered services provided for the medical care and treatment
202 of a recipient who is admitted as an inpatient by a licensed
203 physician or dentist to a hospital licensed under part I of
204 chapter 395. However, the agency shall limit the payment for
205 inpatient hospital services for a Medicaid recipient 21 years of
206 age or older to 45 days or the number of days necessary to
207 comply with the General Appropriations Act. Effective August 1,
208 2012, the agency shall limit payment for hospital emergency
209 department visits for a nonpregnant Medicaid recipient 21 years
210 of age or older to six visits per fiscal year.
211 (a) The agency may implement reimbursement and utilization
212 management reforms in order to comply with any limitations or
213 directions in the General Appropriations Act, which may include,
214 but are not limited to: prior authorization for inpatient
215 psychiatric days; prior authorization for nonemergency hospital
216 inpatient admissions for individuals 21 years of age and older;
217 authorization of emergency and urgent-care admissions within 24
218 hours after admission; enhanced utilization and concurrent
219 review programs for highly utilized services; reduction or
220 elimination of covered days of service; adjusting reimbursement
221 ceilings for variable costs; adjusting reimbursement ceilings
222 for fixed and property costs; and implementing target rates of
223 increase. The agency may limit prior authorization for hospital
224 inpatient services to selected diagnosis-related groups, based
225 on an analysis of the cost and potential for unnecessary
226 hospitalizations represented by certain diagnoses. Admissions
227 for normal delivery and newborns are exempt from requirements
228 for prior authorization. In implementing the provisions of this
229 section related to prior authorization, the agency shall ensure
230 that the process for authorization is accessible 24 hours per
231 day, 7 days per week and authorization is automatically granted
232 when not denied within 4 hours after the request. Authorization
233 procedures must include steps for review of denials. Upon
234 implementing the prior authorization program for hospital
235 inpatient services, the agency shall discontinue its hospital
236 retrospective review program.
237 (b) A licensed hospital maintained primarily for the care
238 and treatment of patients having mental disorders or mental
239 diseases is not eligible to participate in the hospital
240 inpatient portion of the Medicaid program except as provided in
241 federal law. However, the department shall apply for a waiver,
242 within 9 months after June 5, 1991, designed to provide
243 hospitalization services for mental health reasons to children
244 and adults in the most cost-effective and lowest cost setting
245 possible. Such waiver shall include a request for the
246 opportunity to pay for care in hospitals known under federal law
247 as “institutions for mental disease” or “IMD’s.” The waiver
248 proposal shall propose no additional aggregate cost to the state
249 or Federal Government, and shall be conducted in Hillsborough
250 County, Highlands County, Hardee County, Manatee County, and
251 Polk County. The waiver proposal may incorporate competitive
252 bidding for hospital services, comprehensive brokering, prepaid
253 capitated arrangements, or other mechanisms deemed by the
254 department to show promise in reducing the cost of acute care
255 and increasing the effectiveness of preventive care. When
256 developing the waiver proposal, the department shall take into
257 account price, quality, accessibility, linkages of the hospital
258 to community services and family support programs, plans of the
259 hospital to ensure the earliest discharge possible, and the
260 comprehensiveness of the mental health and other health care
261 services offered by participating providers.
262 (c) The agency shall implement a prospective payment
263 methodology for establishing reimbursement rates for inpatient
264 hospital services. Rates shall be calculated annually and take
265 effect July 1 of each year. The methodology shall categorize
266 each inpatient admission into a diagnosis-related group and
267 assign a relative payment weight to the base rate according to
268 the average relative amount of hospital resources used to treat
269 a patient in a specific diagnosis-related group category. The
270 agency may adopt the most recent relative weights calculated and
271 made available by the Nationwide Inpatient Sample maintained by
272 the Agency for Healthcare Research and Quality or may adopt
273 alternative weights if the agency finds that Florida-specific
274 weights deviate with statistical significance from national
275 weights for high-volume diagnosis-related groups. The agency
276 shall establish a single, uniform base rate for all hospitals
277 unless specifically exempt pursuant to s. 409.908(1).
278 1. Adjustments may not be made to the rates after October
279 31 of the state fiscal year in which the rates take effect,
280 except for cases of insufficient collections of
281 intergovernmental transfers authorized under s. 409.908(1) or
282 the General Appropriations Act. In such cases, the agency shall
283 submit a budget amendment or amendments under chapter 216
284 requesting approval of rate reductions by amounts necessary for
285 the aggregate reduction to equal the dollar amount of
286 intergovernmental transfers not collected and the corresponding
287 federal match. Notwithstanding the $1 million limitation on
288 increases to an approved operating budget contained in ss.
289 216.181(11) and 216.292(3), a budget amendment exceeding that
290 dollar amount is subject to notice and objection procedures set
291 forth in s. 216.177.
292 2. Errors in source data or calculations discovered after
293 October 31 must be reconciled in a subsequent rate period.
294 However, the agency may not make any adjustment to a hospital’s
295 reimbursement more than 5 years after a hospital is notified of
296 an audited rate established by the agency. The prohibition
297 against adjustments more than 5 years after notification is
298 remedial and applies to actions by providers involving Medicaid
299 claims for hospital services. Hospital reimbursement is subject
300 to such limits or ceilings as may be established in law or
301 described in the agency’s hospital reimbursement plan. Specific
302 exemptions to the limits or ceilings may be provided in the
303 General Appropriations Act.
304 (d) The agency shall implement a comprehensive utilization
305 management program for hospital neonatal intensive care stays in
306 certain high-volume participating hospitals, select counties, or
307 statewide, and replace existing hospital inpatient utilization
308 management programs for neonatal intensive care admissions. The
309 program shall be designed to manage appropriate admissions and
310 discharges for children being treated in neonatal intensive care
311 units and must seek medically appropriate discharge to the
312 child’s home or other less costly treatment setting. The agency
313 may competitively bid a contract for the selection of a
314 qualified organization to provide neonatal intensive care
315 utilization management services. The agency may seek federal
316 waivers to implement this initiative.
317 (e) The agency may develop and implement a program to
318 reduce the number of hospital readmissions among the non
319 Medicare population eligible in areas 9, 10, and 11.
320 Section 8. Paragraph (e) is added to subsection (13) of
321 section 409.906, Florida Statutes, to read:
322 409.906 Optional Medicaid services.—Subject to specific
323 appropriations, the agency may make payments for services which
324 are optional to the state under Title XIX of the Social Security
325 Act and are furnished by Medicaid providers to recipients who
326 are determined to be eligible on the dates on which the services
327 were provided. Any optional service that is provided shall be
328 provided only when medically necessary and in accordance with
329 state and federal law. Optional services rendered by providers
330 in mobile units to Medicaid recipients may be restricted or
331 prohibited by the agency. Nothing in this section shall be
332 construed to prevent or limit the agency from adjusting fees,
333 reimbursement rates, lengths of stay, number of visits, or
334 number of services, or making any other adjustments necessary to
335 comply with the availability of moneys and any limitations or
336 directions provided for in the General Appropriations Act or
337 chapter 216. If necessary to safeguard the state’s systems of
338 providing services to elderly and disabled persons and subject
339 to the notice and review provisions of s. 216.177, the Governor
340 may direct the Agency for Health Care Administration to amend
341 the Medicaid state plan to delete the optional Medicaid service
342 known as “Intermediate Care Facilities for the Developmentally
343 Disabled.” Optional services may include:
344 (13) HOME AND COMMUNITY-BASED SERVICES.—
345 (e) The agency shall seek federal approval to pay for
346 flexible services for persons with severe mental illness or
347 substance abuse disorders, including, but not limited to,
348 temporary housing assistance. Payments may be made as enhanced
349 capitation rates or incentive payments to managed care plans
350 that meet the requirements of s. 409.968(4).
351 Section 9. Section 409.9064, Florida Statutes, is created
352 to read:
353 409.9064 Medicaid Services for Individuals with Phelan
354 McDermid Syndrome.—The agency shall seek federal approval of a
355 Section 1915(i) state plan option for home and community-based
356 services for individuals diagnosed with Phelan-McDermid
357 Syndrome. Financial eligibility for Medicaid benefits under this
358 plan option will be determined in the same manner as the home
359 and community-based services waiver for persons with
360 developmental disabilities.
361 Section 10. Present subsection (12) of section 409.907,
362 Florida Statutes, is redesignated as subsection (13), and a new
363 subsection (12) is added to that subsection, to read:
364 409.907 Medicaid provider agreements.—The agency may make
365 payments for medical assistance and related services rendered to
366 Medicaid recipients only to an individual or entity who has a
367 provider agreement in effect with the agency, who is performing
368 services or supplying goods in accordance with federal, state,
369 and local law, and who agrees that no person shall, on the
370 grounds of handicap, race, color, or national origin, or for any
371 other reason, be subjected to discrimination under any program
372 or activity for which the provider receives payment from the
373 agency.
374 (12) In accordance with 42 C.F.R. s. 433.318(d)(2)(ii), the
375 agency may certify that a provider is out of business and that
376 any overpayments made to the provider cannot be collected under
377 state law.
378 Section 11. Section 409.9072, Florida Statutes, is created
379 to read:
380 409.9072 Medicaid provider agreements for charter schools
381 and private schools.—
382 (1) Subject to a specific appropriation by the Legislature,
383 the agency shall reimburse private schools as defined in s.
384 1002.01 and schools designated as charter schools under s.
385 1002.33 which are Medicaid providers for school-based services
386 pursuant to the rehabilitative services option provided under 42
387 U.S.C. s. 1396d(a)(13) to children younger than 21 years of age
388 with specified disabilities who are eligible for both Medicaid
389 and part B or part H of the Individuals with Disabilities
390 Education Act (IDEA) or the exceptional student education
391 program, or who have an individualized educational plan.
392 (2) Schools that wish to enroll as Medicaid providers and
393 receive Medicaid reimbursement under this section must apply to
394 the agency for a provider agreement and must agree to:
395 (a) Verify Medicaid eligibility. The agency shall work
396 cooperatively with a private school or a charter school that is
397 a Medicaid provider to facilitate the school’s verification of
398 Medicaid eligibility.
399 (b) Develop and maintain the financial and individual
400 education plan records needed to document the appropriate use of
401 state and federal Medicaid funds.
402 (c) Comply with all state and federal Medicaid laws, rules,
403 regulations, and policies, including, but not limited to, those
404 related to the confidentiality of records and freedom of choice
405 of providers.
406 (d) Be responsible for reimbursing the cost of any state or
407 federal disallowance that results from failure to comply with
408 state or federal Medicaid laws, rules, or regulations.
409 (3) The types of school-based services for which schools
410 may be reimbursed under this section are those included in s.
411 1011.70(1). Private schools and charter schools may not be
412 reimbursed by the agency for providing services that are
413 excluded by that subsection.
414 (4) Within 90 days after a private school or a charter
415 school applies to enroll as a Medicaid provider under this
416 section, the agency may conduct a review to ensure that the
417 school has the capability to comply with its responsibilities
418 under subsection (2). A finding by the agency that the school
419 has the capability to comply does not relieve the school of its
420 responsibility to correct any deficiencies or to reimburse the
421 cost of the state or federal disallowances identified pursuant
422 to any subsequent state or federal audits.
423 (5) For reimbursements to private schools and charter
424 schools under this section, the agency shall apply the
425 reimbursement schedule developed under s. 409.9071(5). Health
426 care practitioners engaged by a school to provide services under
427 this section must be enrolled as Medicaid providers and meet the
428 qualifications specified under 42 C.F.R. s. 440.110, as
429 applicable. Each school’s continued participation in providing
430 Medicaid services under this section is contingent upon the
431 school providing to the agency an annual accounting of how the
432 Medicaid reimbursements are used.
433 (6) For Medicaid provider agreements issued under this
434 section, the agency’s and the school’s confidentiality is waived
435 in relation to the state’s efforts to control Medicaid fraud.
436 The agency and the school shall provide any information or
437 documents relating to this section to the Medicaid Fraud Control
438 Unit in the Department of Legal Affairs, upon request, pursuant
439 to the Attorney General’s authority under s. 409.920.
440 Section 12. Effective July 1, 2017, paragraph (c) of
441 subsection (23) of section 409.908, Florida Statutes, is amended
442 to read:
443 409.908 Reimbursement of Medicaid providers.—Subject to
444 specific appropriations, the agency shall reimburse Medicaid
445 providers, in accordance with state and federal law, according
446 to methodologies set forth in the rules of the agency and in
447 policy manuals and handbooks incorporated by reference therein.
448 These methodologies may include fee schedules, reimbursement
449 methods based on cost reporting, negotiated fees, competitive
450 bidding pursuant to s. 287.057, and other mechanisms the agency
451 considers efficient and effective for purchasing services or
452 goods on behalf of recipients. If a provider is reimbursed based
453 on cost reporting and submits a cost report late and that cost
454 report would have been used to set a lower reimbursement rate
455 for a rate semester, then the provider’s rate for that semester
456 shall be retroactively calculated using the new cost report, and
457 full payment at the recalculated rate shall be effected
458 retroactively. Medicare-granted extensions for filing cost
459 reports, if applicable, shall also apply to Medicaid cost
460 reports. Payment for Medicaid compensable services made on
461 behalf of Medicaid eligible persons is subject to the
462 availability of moneys and any limitations or directions
463 provided for in the General Appropriations Act or chapter 216.
464 Further, nothing in this section shall be construed to prevent
465 or limit the agency from adjusting fees, reimbursement rates,
466 lengths of stay, number of visits, or number of services, or
467 making any other adjustments necessary to comply with the
468 availability of moneys and any limitations or directions
469 provided for in the General Appropriations Act, provided the
470 adjustment is consistent with legislative intent.
471 (23)
472 (c) This subsection applies to the following provider
473 types:
474 1. Inpatient hospitals.
475 2. Outpatient hospitals.
476 3. Nursing homes.
477 3.4. County health departments.
478 4.5. Prepaid health plans.
479 Section 13. Paragraph (a) of subsection (2) of section
480 409.909, Florida Statutes, is amended to read:
481 409.909 Statewide Medicaid Residency Program.—
482 (2) On or before September 15 of each year, the agency
483 shall calculate an allocation fraction to be used for
484 distributing funds to participating hospitals. On or before the
485 final business day of each quarter of a state fiscal year, the
486 agency shall distribute to each participating hospital one
487 fourth of that hospital’s annual allocation calculated under
488 subsection (4). The allocation fraction for each participating
489 hospital is based on the hospital’s number of full-time
490 equivalent residents and the amount of its Medicaid payments. As
491 used in this section, the term:
492 (a) “Full-time equivalent,” or “FTE,” means a resident who
493 is in his or her residency period, with the initial residency
494 period defined as the minimum number of years of training
495 required before the resident may become eligible for board
496 certification by the American Osteopathic Association Bureau of
497 Osteopathic Specialists or the American Board of Medical
498 Specialties in the specialty in which he or she first began
499 training, not to exceed 5 years. The residency specialty is
500 defined as reported using the current residency type codes in
501 the Intern and Resident Information System (IRIS), required by
502 Medicare. A resident training beyond the initial residency
503 period is counted as 0.5 FTE, unless his or her chosen specialty
504 is in primary care, in which case the resident is counted as 1.0
505 FTE. For the purposes of this section, primary care specialties
506 include:
507 1. Family medicine;
508 2. General internal medicine;
509 3. General pediatrics;
510 4. Preventive medicine;
511 5. Geriatric medicine;
512 6. Osteopathic general practice;
513 7. Obstetrics and gynecology;
514 8. Emergency medicine; and
515 9. General surgery; and
516 10. Psychiatry.
517 Section 14. Paragraph (a) of subsection (2) of section
518 409.911, Florida Statutes, is amended, and subsection (10) is
519 added to that section, to read:
520 409.911 Disproportionate share program.—Subject to specific
521 allocations established within the General Appropriations Act
522 and any limitations established pursuant to chapter 216, the
523 agency shall distribute, pursuant to this section, moneys to
524 hospitals providing a disproportionate share of Medicaid or
525 charity care services by making quarterly Medicaid payments as
526 required. Notwithstanding the provisions of s. 409.915, counties
527 are exempt from contributing toward the cost of this special
528 reimbursement for hospitals serving a disproportionate share of
529 low-income patients.
530 (2) The Agency for Health Care Administration shall use the
531 following actual audited data to determine the Medicaid days and
532 charity care to be used in calculating the disproportionate
533 share payment:
534 (a) The average of the 2007, 2008, and 2009 audited
535 disproportionate share data to determine each hospital’s
536 Medicaid days and charity care for the 2016-2017 2015-2016 state
537 fiscal year.
538 (10) Notwithstanding the provisions of this section to the
539 contrary, for the 2016-2017 state fiscal year, the agency shall
540 distribute moneys to hospitals providing a disproportionate
541 share of Medicaid or charity care services as provided in the
542 2016-2017 General Appropriations Act.
543 Section 15. Subsection (3) is added to section 409.9113,
544 Florida Statutes, to read:
545 409.9113 Disproportionate share program for teaching
546 hospitals.—In addition to the payments made under s. 409.911,
547 the agency shall make disproportionate share payments to
548 teaching hospitals, as defined in s. 408.07, for their increased
549 costs associated with medical education programs and for
550 tertiary health care services provided to the indigent. This
551 system of payments must conform to federal requirements and
552 distribute funds in each fiscal year for which an appropriation
553 is made by making quarterly Medicaid payments. Notwithstanding
554 s. 409.915, counties are exempt from contributing toward the
555 cost of this special reimbursement for hospitals serving a
556 disproportionate share of low-income patients. The agency shall
557 distribute the moneys provided in the General Appropriations Act
558 to statutorily defined teaching hospitals and family practice
559 teaching hospitals, as defined in s. 395.805, pursuant to this
560 section. The funds provided for statutorily defined teaching
561 hospitals shall be distributed as provided in the General
562 Appropriations Act. The funds provided for family practice
563 teaching hospitals shall be distributed equally among family
564 practice teaching hospitals.
565 (3) Notwithstanding the provisions of this section to the
566 contrary, for the 2016-2017 state fiscal year, the agency shall
567 make disproportionate share payments to teaching hospitals, as
568 defined in s. 408.07, as provided in the 2016-2017 General
569 Appropriations Act.
570 Section 16. Subsection (3) is added to section 409.9115,
571 Florida Statutes, to read:
572 409.9115 Disproportionate share program for mental health
573 hospitals.—The Agency for Health Care Administration shall
574 design and implement a system of making mental health
575 disproportionate share payments to hospitals that qualify for
576 disproportionate share payments under s. 409.911. This system of
577 payments shall conform with federal requirements and shall
578 distribute funds in each fiscal year for which an appropriation
579 is made by making quarterly Medicaid payments. Notwithstanding
580 s. 409.915, counties are exempt from contributing toward the
581 cost of this special reimbursement for patients.
582 (3) Notwithstanding the provisions of this section to the
583 contrary, for the 2016-2017 state fiscal year, for hospitals
584 that qualify under subsection (2), the agency shall distribute
585 funds for the disproportionate share program for mental health
586 hospitals in the same manner as in the 2015-2016 state fiscal
587 year.
588 Section 17. Subsection (4) is added to section 409.9119,
589 Florida Statutes, to read:
590 409.9119 Disproportionate share program for specialty
591 hospitals for children.—In addition to the payments made under
592 s. 409.911, the Agency for Health Care Administration shall
593 develop and implement a system under which disproportionate
594 share payments are made to those hospitals that are licensed by
595 the state as specialty hospitals for children and were licensed
596 on January 1, 2000, as specialty hospitals for children. This
597 system of payments must conform to federal requirements and must
598 distribute funds in each fiscal year for which an appropriation
599 is made by making quarterly Medicaid payments. Notwithstanding
600 s. 409.915, counties are exempt from contributing toward the
601 cost of this special reimbursement for hospitals that serve a
602 disproportionate share of low-income patients. The agency may
603 make disproportionate share payments to specialty hospitals for
604 children as provided for in the General Appropriations Act.
605 (4) Notwithstanding the provisions of this section to the
606 contrary, for the 2016-2017 state fiscal year, for hospitals
607 achieving full compliance under subsection (3), the agency shall
608 make disproportionate share payments to specialty hospitals for
609 children as provided in the 2016-2017 General Appropriations
610 Act.
611 Section 18. Subsection (5) of section 409.9128, Florida
612 Statutes, is amended to read:
613 409.9128 Requirements for providing emergency services and
614 care.—
615 (5) Reimbursement for services provided to an enrollee of a
616 managed care plan under this section by a provider who does not
617 have a contract with the managed care plan shall be the lesser
618 of:
619 (a) The provider’s charges;
620 (b) The usual and customary provider charges for similar
621 services in the community where the services were provided;
622 (c) The charge mutually agreed to by the entity and the
623 provider within 60 days after submittal of the claim; or
624 (d) The Medicaid rate, as provided in s. 409.967(2)(b).
625 Section 19. Paragraph (b) of subsection (2) of section
626 409.967, Florida Statutes, is amended to read:
627 409.967 Managed care plan accountability.—
628 (2) The agency shall establish such contract requirements
629 as are necessary for the operation of the statewide managed care
630 program. In addition to any other provisions the agency may deem
631 necessary, the contract must require:
632 (b) Emergency services.—Managed care plans shall pay for
633 services required by ss. 395.1041 and 401.45 and rendered by a
634 noncontracted provider. The plans must comply with s. 641.3155.
635 Reimbursement for services under this paragraph is the lesser
636 of:
637 1. The provider’s charges;
638 2. The usual and customary provider charges for similar
639 services in the community where the services were provided;
640 3. The charge mutually agreed to by the entity and the
641 provider within 60 days after submittal of the claim; or
642 4. The Medicaid rate, which, for the purposes of this
643 paragraph, means the amount the provider would collect from the
644 agency on a fee-for-service basis, less any amounts for the
645 indirect costs of medical education and the direct costs of
646 graduate medical education that are otherwise included in the
647 agency’s fee-for-service payment, as required under 42 U.S.C. s.
648 1396u-2(b)(2)(D) The rate the agency would have paid on the most
649 recent October 1st.
650
651 For the purpose of establishing the amounts specified in
652 subparagraph 4., the agency shall publish on its website
653 annually, or more frequently as needed, the applicable fee-for
654 service fee schedules and their effective dates, less any
655 amounts for indirect costs of medical education and direct costs
656 of graduate medical education that are otherwise included in the
657 agency’s fee-for-service payments.
658 Section 20. Present subsection (4) of section 409.968,
659 Florida Statutes, is redesignated as subsection (5) and a new
660 subsection (4) is added to that section, to read:
661 409.968 Managed care plan payments.—
662 (4)(a) Subject to a specific appropriation and federal
663 approval under s. 409.906(13)(e), the agency shall establish a
664 payment methodology to fund managed care plans for flexible
665 services for persons with severe mental illness and substance
666 abuse disorders, including, but not limited to, temporary
667 housing assistance. A managed care plan eligible for these
668 payments must do all of the following:
669 1. Participate as a specialty plan for severe mental
670 illness or substance abuse disorders or participate in counties
671 designated by the General Appropriations Act;
672 2. Include providers of behavioral health services pursuant
673 to chapters 394 and 397 in the managed care plan’s provider
674 network; and
675 3. Document a capability to provide housing assistance
676 through agreements with housing providers, relationships with
677 local housing coalitions, and other appropriate arrangements.
678 (b) After receiving payments authorized by this section for
679 at least 1 year, a managed care plan must document the results
680 of its efforts to maintain the target population in stable
681 housing up to the maximum duration allowed under federal
682 approval.
683 Section 21. Subsections (1) and (6) of section 409.975,
684 Florida Statutes, are amended to read:
685 409.975 Managed care plan accountability.—In addition to
686 the requirements of s. 409.967, plans and providers
687 participating in the managed medical assistance program shall
688 comply with the requirements of this section.
689 (1) PROVIDER NETWORKS.—Managed care plans must develop and
690 maintain provider networks that meet the medical needs of their
691 enrollees in accordance with standards established pursuant to
692 s. 409.967(2)(c). Except as provided in this section, managed
693 care plans may limit the providers in their networks based on
694 credentials, quality indicators, and price.
695 (a) Plans must include all providers in the region that are
696 classified by the agency as essential Medicaid providers, unless
697 the agency approves, in writing, an alternative arrangement for
698 securing the types of services offered by the essential
699 providers. Providers are essential for serving Medicaid
700 enrollees if they offer services that are not available from any
701 other provider within a reasonable access standard, or if they
702 provided a substantial share of the total units of a particular
703 service used by Medicaid patients within the region during the
704 last 3 years and the combined capacity of other service
705 providers in the region is insufficient to meet the total needs
706 of the Medicaid patients. The agency may not classify physicians
707 and other practitioners as essential providers. The agency, at a
708 minimum, shall determine which providers in the following
709 categories are essential Medicaid providers:
710 1. Federally qualified health centers.
711 2. Statutory teaching hospitals as defined in s.
712 408.07(45).
713 3. Hospitals that are trauma centers as defined in s.
714 395.4001(14).
715 4. Hospitals located at least 25 miles from any other
716 hospital with similar services.
717
718 Managed care plans that have not contracted with all essential
719 providers in the region as of the first date of recipient
720 enrollment, or with whom an essential provider has terminated
721 its contract, must negotiate in good faith with such essential
722 providers for 1 year or until an agreement is reached, whichever
723 is first. Payments for services rendered by a nonparticipating
724 essential provider shall be made at the applicable Medicaid rate
725 as of the first day of the contract between the agency and the
726 plan. A rate schedule for all essential providers shall be
727 attached to the contract between the agency and the plan. After
728 1 year, managed care plans that are unable to contract with
729 essential providers shall notify the agency and propose an
730 alternative arrangement for securing the essential services for
731 Medicaid enrollees. The arrangement must rely on contracts with
732 other participating providers, regardless of whether those
733 providers are located within the same region as the
734 nonparticipating essential service provider. If the alternative
735 arrangement is approved by the agency, payments to
736 nonparticipating essential providers after the date of the
737 agency’s approval shall equal 90 percent of the applicable
738 Medicaid rate. Except for payment for emergency services, if the
739 alternative arrangement is not approved by the agency, payment
740 to nonparticipating essential providers shall equal 110 percent
741 of the applicable Medicaid rate.
742 (b) Certain providers are statewide resources and essential
743 providers for all managed care plans in all regions. All managed
744 care plans must include these essential providers in their
745 networks. Statewide essential providers include:
746 1. Faculty plans of Florida medical schools.
747 2. Regional perinatal intensive care centers as defined in
748 s. 383.16(2).
749 3. Hospitals licensed as specialty children’s hospitals as
750 defined in s. 395.002(28).
751 4. Accredited and integrated systems serving medically
752 complex children which comprise that are comprised of separately
753 licensed, but commonly owned, health care providers delivering
754 at least the following services: medical group home, in-home and
755 outpatient nursing care and therapies, pharmacy services,
756 durable medical equipment, and Prescribed Pediatric Extended
757 Care.
758
759 Managed care plans that have not contracted with all statewide
760 essential providers in all regions as of the first date of
761 recipient enrollment must continue to negotiate in good faith.
762 Payments to physicians on the faculty of nonparticipating
763 Florida medical schools shall be made at the applicable Medicaid
764 rate. Payments for services rendered by regional perinatal
765 intensive care centers shall be made at the applicable Medicaid
766 rate as of the first day of the contract between the agency and
767 the plan. Except for payments for emergency services, payments
768 to nonparticipating specialty children’s hospitals shall equal
769 the highest rate established by contract between that provider
770 and any other Medicaid managed care plan.
771 (c) After 12 months of active participation in a plan’s
772 network, the plan may exclude any essential provider from the
773 network for failure to meet quality or performance criteria. If
774 the plan excludes an essential provider from the plan, the plan
775 must provide written notice to all recipients who have chosen
776 that provider for care. The notice shall be provided at least 30
777 days before the effective date of the exclusion. For the
778 purposes of this paragraph, the term “essential provider”
779 includes providers determined by the agency to be essential
780 Medicaid providers under paragraph (a) and the statewide
781 essential providers specified in paragraph (b).
782 (d) The applicable Medicaid rates for emergency services
783 paid by a plan under this section to a provider with which the
784 plan does not have an active contract, shall be determined under
785 the requirements of s. 409.967(2)(b).
786 (e) Each managed care plan must offer a network contract to
787 each home medical equipment and supplies provider in the region
788 which meets quality and fraud prevention and detection standards
789 established by the plan and which agrees to accept the lowest
790 price previously negotiated between the plan and another such
791 provider.
792 (6) PROVIDER PAYMENT.—Managed care plans and hospitals
793 shall negotiate mutually acceptable rates, methods, and terms of
794 payment. For rates, methods, and terms of payment negotiated
795 after the contract between the agency and the plan is executed,
796 plans shall pay hospitals, at a minimum, the rate the agency
797 would have paid on the first day of the contract between the
798 provider and the plan. Such payments to hospitals may not exceed
799 120 percent of the rate the agency would have paid on the first
800 day of the contract between the provider and the plan, unless
801 specifically approved by the agency. Payment rates may be
802 updated periodically.
803 Section 22. Paragraph (b) of subsection (3) of section
804 624.91, Florida Statutes, is amended to read:
805 624.91 The Florida Healthy Kids Corporation Act.—
806 (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
807 following individuals are eligible for state-funded assistance
808 in paying Florida Healthy Kids premiums:
809 (b) Notwithstanding s. 409.814, a legal alien aliens who is
810 are enrolled in the Florida Healthy Kids program as of January
811 31, 2004, who does do not qualify for Title XXI federal funds
812 because he or she is they are not a lawfully residing child
813 qualified aliens as defined in s. 409.811.
814 Section 23. Subsection (6) of section 641.513, Florida
815 Statutes, is amended, and subsection (7) is added to that
816 section, to read:
817 641.513 Requirements for providing emergency services and
818 care.—
819 (6) Reimbursement for services under this section provided
820 to subscribers who are Medicaid recipients by a provider for
821 whom no contract exists between the provider and the health
822 maintenance organization shall be determined under chapter 409
823 the lesser of:
824 (a) The provider’s charges;
825 (b) The usual and customary provider charges for similar
826 services in the community where the services were provided;
827 (c) The charge mutually agreed to by the entity and the
828 provider within 60 days after submittal of the claim; or
829 (d) The Medicaid rate.
830 (7) Reimbursement for services under this section provided
831 to subscribers who are enrolled in a health maintenance
832 organization pursuant to s. 624.91 by a provider for whom no
833 contract exists between the provider and the health maintenance
834 organization shall be the lesser of:
835 (a) The provider’s charges;
836 (b) The usual and customary provider charges for similar
837 services in the community where the services were provided;
838 (c) The charge mutually agreed to by the entity and the
839 provider within 60 days after submittal of the claim; or
840 (d) The Medicaid rate.
841 Section 24. Subject to federal approval and adoption of a
842 contract amendment with the Agency for Health Care
843 Administration, an organization that is currently authorized to
844 provide Program of All-Inclusive Care for the Elderly (PACE)
845 services in southeast Florida and that is granted authority
846 under section 18 of chapter 2012-33, Laws of Florida, for up to
847 150 enrollee slots to serve frail elders residing in Broward
848 County may also use those PACE slots for frail elders residing
849 in Miami-Dade County.
850 Section 25. Subject to federal approval of the application
851 to be a site for the Program of All-inclusive Care for the
852 Elderly (PACE), the Agency for Health Care Administration shall
853 contract with one private, not-for-profit hospice organization
854 located in Escambia County that owns and manages health care
855 organizations licensed in Hospice Service Areas 1, 2A, and 2B
856 which provide comprehensive services, including, but not limited
857 to, hospice and palliative care, to frail elders who reside in
858 those Hospice Service Areas. The organization is exempt from the
859 requirements of chapter 641, Florida Statutes. The agency, in
860 consultation with the Department of Elderly Affairs and subject
861 to the appropriation of funds by the Legislature, shall approve
862 up to 100 initial enrollees in the Program of All-inclusive Care
863 for the Elderly established by the organization to serve frail
864 elders who reside in Hospice Service Areas 1, 2A, and 2B.
865 Section 26. Except as otherwise expressly provided in this
866 act and except for this section, which shall take effect upon
867 this act becoming a law, this act shall take effect July 1,
868 2016.
869
870 ================= T I T L E A M E N D M E N T ================
871 And the title is amended as follows:
872 Delete everything before the enacting clause
873 and insert:
874 A bill to be entitled
875 An act relating to health care services; amending s.
876 322.143, F.S.; providing an exception to the
877 prohibition against a private entity swiping an
878 individual’s driver license or identification card for
879 certain entities for certain purposes; amending s.
880 395.602, F.S.; including specified hospitals in the
881 definition of “rural hospital”; amending s. 409.285,
882 F.S.; requiring appeals related to Medicaid programs
883 directly administered by the Agency for Health Care
884 Administration to be directed to the agency; providing
885 requirements for appeals directed to the agency;
886 providing an exemption from the uniform rules of
887 procedure and from a requirement that certain
888 proceedings be heard before an administrative law
889 judge for specified hearings; requiring the agency to
890 seek federal approval of its authority to oversee
891 appeals; providing that appeals related to Medicaid
892 programs administered by the Agency for Persons with
893 Disabilities are subject to that agency’s hearing
894 rights process; amending s. 409.811, F.S.; defining
895 the term “lawfully residing child”; deleting the
896 definition of the term “qualified alien”; conforming
897 provisions to changes made by the act; amending s.
898 409.814, F.S.; revising eligibility for the Florida
899 Kidcare program to conform to changes made by the act;
900 clarifying that undocumented immigrants are excluded
901 from eligibility; amending s. 409.904, F.S.; providing
902 eligibility for optional payments for medical
903 assistance and related services for certain lawfully
904 residing children; clarifying that undocumented
905 immigrants are excluded from eligibility for optional
906 Medicaid payments or related services; amending s.
907 409.905, F.S.; deleting the limitation on the number
908 of hospital emergency department visits that may be
909 paid for by the Agency for Health Care Administration
910 for certain recipients; amending s. 409.906, F.S.;
911 directing the agency to seek federal approval to
912 provide temporary housing assistance for certain
913 persons; creating s. 409.9064, F.S.; directing the
914 agency to seek federal approval to provide home and
915 community-based services for individuals diagnosed
916 with Phelan-McDermid Syndrome; providing a method for
917 determining financial eligibility for Medicaid
918 benefits in certain circumstances; amending s.
919 409.907, F.S.; authorizing the agency to certify that
920 a Medicaid provider is out of business; creating s.
921 409.9072, F.S.; directing the agency to pay private
922 schools and charter schools that are Medicaid
923 providers for specified school-based services under
924 certain parameters; authorizing the agency to review a
925 school that has applied to the program for capability
926 requirements; providing a reimbursement schedule;
927 providing for a waiver of agency and school
928 confidentiality under certain circumstances; amending
929 s. 409.908, F.S.; revising the list of provider types
930 that are subject to certain statutory provisions
931 relating to the establishment of rates; amending s.
932 409.909; adding psychiatry to a list of primary care
933 specialties under the Statewide Medicaid Residency
934 Program; amending s. 409.911, F.S.; updating the
935 fiscal year for determining each hospital’s Medicaid
936 days and charity care; providing an exception for the
937 distribution of moneys to certain hospitals for the
938 2016-2017 state fiscal year; amending ss. 409.9113,
939 409.9115, and 409.9119, F.S.; providing an exception
940 for the distribution of moneys to certain hospitals
941 for the 2016-2017 state fiscal year; amending s.
942 409.9128, F.S.; conforming provisions to changes made
943 by the act; amending s. 409.967, F.S.; defining the
944 term “Medicaid rate” for the purpose of determining
945 specified managed care plan payments for emergency
946 services in compliance with federal law; requiring
947 annual publication of fee schedules on the agency’s
948 website; amending s. 409.968, F.S.; directing the
949 agency to establish a payment methodology for managed
950 care plans providing housing assistance to specified
951 persons; amending s. 409.975, F.S.; providing for the
952 determination of applicable Medicaid rates for
953 emergency services; defining the term “essential
954 provider”; deleting requirements relating to
955 contracted rates between managed care plans and
956 hospitals; conforming provisions to changes made by
957 the act; amending s. 624.91, F.S.; conforming
958 provisions to changes made by the act; amending s.
959 641.513, F.S.; specifying parameters for payments by a
960 health maintenance organization to a noncontracted
961 provider of emergency services under certain
962 circumstances; conforming provisions to changes made
963 by the act; authorizing a Program of All-Inclusive
964 Care for the Elderly organization granted certain
965 enrollee slots for frail elders residing in Broward
966 County to also use the slots for enrollees residing in
967 Miami-Dade County; authorizing the agency to contract
968 with an organization in Escambia County to provide
969 services under the federal Program of All-inclusive
970 Care for the Elderly in specified areas; exempting the
971 organization from ch. 641, F.S., relating to health
972 care service programs; authorizing enrollment slots
973 for the program in such areas, subject to
974 appropriation; providing effective dates.