Florida Senate - 2017 CS for SB 694
By the Committee on Health Policy; and Senators Hutson and
Passidomo
588-02954-17 2017694c1
1 A bill to be entitled
2 An act relating to consolidation of Medicaid waiver
3 programs; amending s. 409.904, F.S.; authorizing any
4 state agency or department involved in providing
5 health, social, or human services to make payments for
6 medical assistance for certain persons diagnosed with
7 Acquired Immune Deficiency Syndrome (AIDS); amending
8 s. 409.906, F.S.; removing the Agency for Health Care
9 Administration’s ability to consolidate certain home
10 and community-based services; amending s. 409.912,
11 F.S.; deleting the requirement that the agency
12 implement a Medicaid prescription drug management
13 system; amending s. 409.979, F.S.; requiring that
14 Medicaid recipients enrolled in certain home and
15 community-based service Medicaid waivers be
16 transitioned into the long-term care managed care
17 program by January 1, 2018; requiring the agency to
18 seek federal approval to terminate certain waiver
19 programs once all eligible Medicaid recipients have
20 transitioned into the long-term care managed care
21 program; amending ss. 393.0661 and 409.968, F.S.;
22 conforming cross-references; providing an effective
23 date.
24
25 Be It Enacted by the Legislature of the State of Florida:
26
27 Section 1. Subsection (11) is added to section 409.904,
28 Florida Statutes, to read:
29 409.904 Optional payments for eligible persons.—The agency
30 may make payments for medical assistance and related services on
31 behalf of the following persons who are determined to be
32 eligible subject to the income, assets, and categorical
33 eligibility tests set forth in federal and state law. Payment on
34 behalf of these Medicaid eligible persons is subject to the
35 availability of moneys and any limitations established by the
36 General Appropriations Act or chapter 216.
37 (11) Subject to federal waiver approval, a person diagnosed
38 with Acquired Immune Deficiency Syndrome (AIDS), who has an
39 AIDS-related opportunistic infection, who is at risk of
40 hospitalization as determined by the agency or its designee, and
41 whose income is at, or below, 300 percent of the federal benefit
42 rate.
43 Section 2. Paragraph (b) of subsection (13) of section
44 409.906, Florida Statutes, is amended to read:
45 409.906 Optional Medicaid services.—Subject to specific
46 appropriations, the agency may make payments for services which
47 are optional to the state under Title XIX of the Social Security
48 Act and are furnished by Medicaid providers to recipients who
49 are determined to be eligible on the dates on which the services
50 were provided. Any optional service that is provided shall be
51 provided only when medically necessary and in accordance with
52 state and federal law. Optional services rendered by providers
53 in mobile units to Medicaid recipients may be restricted or
54 prohibited by the agency. Nothing in this section shall be
55 construed to prevent or limit the agency from adjusting fees,
56 reimbursement rates, lengths of stay, number of visits, or
57 number of services, or making any other adjustments necessary to
58 comply with the availability of moneys and any limitations or
59 directions provided for in the General Appropriations Act or
60 chapter 216. If necessary to safeguard the state’s systems of
61 providing services to elderly and disabled persons and subject
62 to the notice and review provisions of s. 216.177, the Governor
63 may direct the Agency for Health Care Administration to amend
64 the Medicaid state plan to delete the optional Medicaid service
65 known as “Intermediate Care Facilities for the Developmentally
66 Disabled.” Optional services may include:
67 (13) HOME AND COMMUNITY-BASED SERVICES.—
68 (b) The agency may consolidate types of services offered in
69 the Aged and Disabled Waiver, the Channeling Waiver, the Project
70 AIDS Care Waiver, and the Traumatic Brain and Spinal Cord Injury
71 Waiver programs in order to group similar services under a
72 single service, or continue a service upon evidence of the need
73 for including a particular service type in a particular waiver.
74 The agency is authorized to seek a Medicaid state plan amendment
75 or federal waiver approval to implement this policy.
76 Section 3. Paragraph (a) of subsection (8) of section
77 409.912, Florida Statutes, is amended to read:
78 409.912 Cost-effective purchasing of health care.—The
79 agency shall purchase goods and services for Medicaid recipients
80 in the most cost-effective manner consistent with the delivery
81 of quality medical care. To ensure that medical services are
82 effectively utilized, the agency may, in any case, require a
83 confirmation or second physician’s opinion of the correct
84 diagnosis for purposes of authorizing future services under the
85 Medicaid program. This section does not restrict access to
86 emergency services or poststabilization care services as defined
87 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
88 shall be rendered in a manner approved by the agency. The agency
89 shall maximize the use of prepaid per capita and prepaid
90 aggregate fixed-sum basis services when appropriate and other
91 alternative service delivery and reimbursement methodologies,
92 including competitive bidding pursuant to s. 287.057, designed
93 to facilitate the cost-effective purchase of a case-managed
94 continuum of care. The agency shall also require providers to
95 minimize the exposure of recipients to the need for acute
96 inpatient, custodial, and other institutional care and the
97 inappropriate or unnecessary use of high-cost services. The
98 agency shall contract with a vendor to monitor and evaluate the
99 clinical practice patterns of providers in order to identify
100 trends that are outside the normal practice patterns of a
101 provider’s professional peers or the national guidelines of a
102 provider’s professional association. The vendor must be able to
103 provide information and counseling to a provider whose practice
104 patterns are outside the norms, in consultation with the agency,
105 to improve patient care and reduce inappropriate utilization.
106 The agency may mandate prior authorization, drug therapy
107 management, or disease management participation for certain
108 populations of Medicaid beneficiaries, certain drug classes, or
109 particular drugs to prevent fraud, abuse, overuse, and possible
110 dangerous drug interactions. The Pharmaceutical and Therapeutics
111 Committee shall make recommendations to the agency on drugs for
112 which prior authorization is required. The agency shall inform
113 the Pharmaceutical and Therapeutics Committee of its decisions
114 regarding drugs subject to prior authorization. The agency is
115 authorized to limit the entities it contracts with or enrolls as
116 Medicaid providers by developing a provider network through
117 provider credentialing. The agency may competitively bid single
118 source-provider contracts if procurement of goods or services
119 results in demonstrated cost savings to the state without
120 limiting access to care. The agency may limit its network based
121 on the assessment of beneficiary access to care, provider
122 availability, provider quality standards, time and distance
123 standards for access to care, the cultural competence of the
124 provider network, demographic characteristics of Medicaid
125 beneficiaries, practice and provider-to-beneficiary standards,
126 appointment wait times, beneficiary use of services, provider
127 turnover, provider profiling, provider licensure history,
128 previous program integrity investigations and findings, peer
129 review, provider Medicaid policy and billing compliance records,
130 clinical and medical record audits, and other factors. Providers
131 are not entitled to enrollment in the Medicaid provider network.
132 The agency shall determine instances in which allowing Medicaid
133 beneficiaries to purchase durable medical equipment and other
134 goods is less expensive to the Medicaid program than long-term
135 rental of the equipment or goods. The agency may establish rules
136 to facilitate purchases in lieu of long-term rentals in order to
137 protect against fraud and abuse in the Medicaid program as
138 defined in s. 409.913. The agency may seek federal waivers
139 necessary to administer these policies.
140 (8)(a) The agency shall implement a Medicaid prescribed
141 drug spending-control program that includes the following
142 components:
143 1. A Medicaid preferred drug list, which shall be a listing
144 of cost-effective therapeutic options recommended by the
145 Medicaid Pharmacy and Therapeutics Committee established
146 pursuant to s. 409.91195 and adopted by the agency for each
147 therapeutic class on the preferred drug list. At the discretion
148 of the committee, and when feasible, the preferred drug list
149 should include at least two products in a therapeutic class. The
150 agency may post the preferred drug list and updates to the list
151 on an Internet website without following the rulemaking
152 procedures of chapter 120. Antiretroviral agents are excluded
153 from the preferred drug list. The agency shall also limit the
154 amount of a prescribed drug dispensed to no more than a 34-day
155 supply unless the drug products’ smallest marketed package is
156 greater than a 34-day supply, or the drug is determined by the
157 agency to be a maintenance drug in which case a 100-day maximum
158 supply may be authorized. The agency may seek any federal
159 waivers necessary to implement these cost-control programs and
160 to continue participation in the federal Medicaid rebate
161 program, or alternatively to negotiate state-only manufacturer
162 rebates. The agency may adopt rules to administer this
163 subparagraph. The agency shall continue to provide unlimited
164 contraceptive drugs and items. The agency must establish
165 procedures to ensure that:
166 a. There is a response to a request for prior consultation
167 by telephone or other telecommunication device within 24 hours
168 after receipt of a request for prior consultation; and
169 b. A 72-hour supply of the drug prescribed is provided in
170 an emergency or when the agency does not provide a response
171 within 24 hours as required by sub-subparagraph a.
172 2. Reimbursement to pharmacies for Medicaid prescribed
173 drugs shall be set at the lowest of: the average wholesale price
174 (AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
175 plus 1.5 percent, the federal upper limit (FUL), the state
176 maximum allowable cost (SMAC), or the usual and customary (UAC)
177 charge billed by the provider.
178 3. The agency shall develop and implement a process for
179 managing the drug therapies of Medicaid recipients who are using
180 significant numbers of prescribed drugs each month. The
181 management process may include, but is not limited to,
182 comprehensive, physician-directed medical-record reviews, claims
183 analyses, and case evaluations to determine the medical
184 necessity and appropriateness of a patient’s treatment plan and
185 drug therapies. The agency may contract with a private
186 organization to provide drug-program-management services. The
187 Medicaid drug benefit management program shall include
188 initiatives to manage drug therapies for HIV/AIDS patients,
189 patients using 20 or more unique prescriptions in a 180-day
190 period, and the top 1,000 patients in annual spending. The
191 agency shall enroll any Medicaid recipient in the drug benefit
192 management program if he or she meets the specifications of this
193 provision and is not enrolled in a Medicaid health maintenance
194 organization.
195 4. The agency may limit the size of its pharmacy network
196 based on need, competitive bidding, price negotiations,
197 credentialing, or similar criteria. The agency shall give
198 special consideration to rural areas in determining the size and
199 location of pharmacies included in the Medicaid pharmacy
200 network. A pharmacy credentialing process may include criteria
201 such as a pharmacy’s full-service status, location, size,
202 patient educational programs, patient consultation, disease
203 management services, and other characteristics. The agency may
204 impose a moratorium on Medicaid pharmacy enrollment if it is
205 determined that it has a sufficient number of Medicaid
206 participating providers. The agency must allow dispensing
207 practitioners to participate as a part of the Medicaid pharmacy
208 network regardless of the practitioner’s proximity to any other
209 entity that is dispensing prescription drugs under the Medicaid
210 program. A dispensing practitioner must meet all credentialing
211 requirements applicable to his or her practice, as determined by
212 the agency.
213 5. The agency shall develop and implement a program that
214 requires Medicaid practitioners who prescribe drugs to use a
215 counterfeit-proof prescription pad for Medicaid prescriptions.
216 The agency shall require the use of standardized counterfeit
217 proof prescription pads by Medicaid-participating prescribers or
218 prescribers who write prescriptions for Medicaid recipients. The
219 agency may implement the program in targeted geographic areas or
220 statewide.
221 6. The agency may enter into arrangements that require
222 manufacturers of generic drugs prescribed to Medicaid recipients
223 to provide rebates of at least 15.1 percent of the average
224 manufacturer price for the manufacturer’s generic products.
225 These arrangements shall require that if a generic-drug
226 manufacturer pays federal rebates for Medicaid-reimbursed drugs
227 at a level below 15.1 percent, the manufacturer must provide a
228 supplemental rebate to the state in an amount necessary to
229 achieve a 15.1-percent rebate level.
230 7. The agency may establish a preferred drug list as
231 described in this subsection, and, pursuant to the establishment
232 of such preferred drug list, negotiate supplemental rebates from
233 manufacturers that are in addition to those required by Title
234 XIX of the Social Security Act and at no less than 14 percent of
235 the average manufacturer price as defined in 42 U.S.C. s. 1936
236 on the last day of a quarter unless the federal or supplemental
237 rebate, or both, equals or exceeds 29 percent. There is no upper
238 limit on the supplemental rebates the agency may negotiate. The
239 agency may determine that specific products, brand-name or
240 generic, are competitive at lower rebate percentages. Agreement
241 to pay the minimum supplemental rebate percentage guarantees a
242 manufacturer that the Medicaid Pharmaceutical and Therapeutics
243 Committee will consider a product for inclusion on the preferred
244 drug list. However, a pharmaceutical manufacturer is not
245 guaranteed placement on the preferred drug list by simply paying
246 the minimum supplemental rebate. Agency decisions will be made
247 on the clinical efficacy of a drug and recommendations of the
248 Medicaid Pharmaceutical and Therapeutics Committee, as well as
249 the price of competing products minus federal and state rebates.
250 The agency may contract with an outside agency or contractor to
251 conduct negotiations for supplemental rebates. For the purposes
252 of this section, the term “supplemental rebates” means cash
253 rebates. Value-added programs as a substitution for supplemental
254 rebates are prohibited. The agency may seek any federal waivers
255 to implement this initiative.
256 8. The agency shall expand home delivery of pharmacy
257 products. The agency may amend the state plan and issue a
258 procurement, as necessary, in order to implement this program.
259 The procurements must include agreements with a pharmacy or
260 pharmacies located in the state to provide mail order delivery
261 services at no cost to the recipients who elect to receive home
262 delivery of pharmacy products. The procurement must focus on
263 serving recipients with chronic diseases for which pharmacy
264 expenditures represent a significant portion of Medicaid
265 pharmacy expenditures or which impact a significant portion of
266 the Medicaid population. The agency may seek and implement any
267 federal waivers necessary to implement this subparagraph.
268 9. The agency shall limit to one dose per month any drug
269 prescribed to treat erectile dysfunction.
270 10.a. The agency may implement a Medicaid behavioral drug
271 management system. The agency may contract with a vendor that
272 has experience in operating behavioral drug management systems
273 to implement this program. The agency may seek federal waivers
274 to implement this program.
275 b. The agency, in conjunction with the Department of
276 Children and Families, may implement the Medicaid behavioral
277 drug management system that is designed to improve the quality
278 of care and behavioral health prescribing practices based on
279 best practice guidelines, improve patient adherence to
280 medication plans, reduce clinical risk, and lower prescribed
281 drug costs and the rate of inappropriate spending on Medicaid
282 behavioral drugs. The program may include the following
283 elements:
284 (I) Provide for the development and adoption of best
285 practice guidelines for behavioral health-related drugs such as
286 antipsychotics, antidepressants, and medications for treating
287 bipolar disorders and other behavioral conditions; translate
288 them into practice; review behavioral health prescribers and
289 compare their prescribing patterns to a number of indicators
290 that are based on national standards; and determine deviations
291 from best practice guidelines.
292 (II) Implement processes for providing feedback to and
293 educating prescribers using best practice educational materials
294 and peer-to-peer consultation.
295 (III) Assess Medicaid beneficiaries who are outliers in
296 their use of behavioral health drugs with regard to the numbers
297 and types of drugs taken, drug dosages, combination drug
298 therapies, and other indicators of improper use of behavioral
299 health drugs.
300 (IV) Alert prescribers to patients who fail to refill
301 prescriptions in a timely fashion, are prescribed multiple same
302 class behavioral health drugs, and may have other potential
303 medication problems.
304 (V) Track spending trends for behavioral health drugs and
305 deviation from best practice guidelines.
306 (VI) Use educational and technological approaches to
307 promote best practices, educate consumers, and train prescribers
308 in the use of practice guidelines.
309 (VII) Disseminate electronic and published materials.
310 (VIII) Hold statewide and regional conferences.
311 (IX) Implement a disease management program with a model
312 quality-based medication component for severely mentally ill
313 individuals and emotionally disturbed children who are high
314 users of care.
315 11. The agency shall implement a Medicaid prescription drug
316 management system.
317 a. The agency may contract with a vendor that has
318 experience in operating prescription drug management systems in
319 order to implement this system. Any management system that is
320 implemented in accordance with this subparagraph must rely on
321 cooperation between physicians and pharmacists to determine
322 appropriate practice patterns and clinical guidelines to improve
323 the prescribing, dispensing, and use of drugs in the Medicaid
324 program. The agency may seek federal waivers to implement this
325 program.
326 b. The drug management system must be designed to improve
327 the quality of care and prescribing practices based on best
328 practice guidelines, improve patient adherence to medication
329 plans, reduce clinical risk, and lower prescribed drug costs and
330 the rate of inappropriate spending on Medicaid prescription
331 drugs. The program must:
332 (I) Provide for the adoption of best practice guidelines
333 for the prescribing and use of drugs in the Medicaid program,
334 including translating best practice guidelines into practice;
335 reviewing prescriber patterns and comparing them to indicators
336 that are based on national standards and practice patterns of
337 clinical peers in their community, statewide, and nationally;
338 and determine deviations from best practice guidelines.
339 (II) Implement processes for providing feedback to and
340 educating prescribers using best practice educational materials
341 and peer-to-peer consultation.
342 (III) Assess Medicaid recipients who are outliers in their
343 use of a single or multiple prescription drugs with regard to
344 the numbers and types of drugs taken, drug dosages, combination
345 drug therapies, and other indicators of improper use of
346 prescription drugs.
347 (IV) Alert prescribers to recipients who fail to refill
348 prescriptions in a timely fashion, are prescribed multiple drugs
349 that may be redundant or contraindicated, or may have other
350 potential medication problems.
351 11.12. The agency may contract for drug rebate
352 administration, including, but not limited to, calculating
353 rebate amounts, invoicing manufacturers, negotiating disputes
354 with manufacturers, and maintaining a database of rebate
355 collections.
356 12.13. The agency may specify the preferred daily dosing
357 form or strength for the purpose of promoting best practices
358 with regard to the prescribing of certain drugs as specified in
359 the General Appropriations Act and ensuring cost-effective
360 prescribing practices.
361 13.14. The agency may require prior authorization for
362 Medicaid-covered prescribed drugs. The agency may prior
363 authorize the use of a product:
364 a. For an indication not approved in labeling;
365 b. To comply with certain clinical guidelines; or
366 c. If the product has the potential for overuse, misuse, or
367 abuse.
368
369 The agency may require the prescribing professional to provide
370 information about the rationale and supporting medical evidence
371 for the use of a drug. The agency shall post prior
372 authorization, step-edit criteria and protocol, and updates to
373 the list of drugs that are subject to prior authorization on the
374 agency’s Internet website within 21 days after the prior
375 authorization and step-edit criteria and protocol and updates
376 are approved by the agency. For purposes of this subparagraph,
377 the term “step-edit” means an automatic electronic review of
378 certain medications subject to prior authorization.
379 14.15. The agency, in conjunction with the Pharmaceutical
380 and Therapeutics Committee, may require age-related prior
381 authorizations for certain prescribed drugs. The agency may
382 preauthorize the use of a drug for a recipient who may not meet
383 the age requirement or may exceed the length of therapy for use
384 of this product as recommended by the manufacturer and approved
385 by the Food and Drug Administration. Prior authorization may
386 require the prescribing professional to provide information
387 about the rationale and supporting medical evidence for the use
388 of a drug.
389 15.16. The agency shall implement a step-therapy prior
390 authorization approval process for medications excluded from the
391 preferred drug list. Medications listed on the preferred drug
392 list must be used within the previous 12 months before the
393 alternative medications that are not listed. The step-therapy
394 prior authorization may require the prescriber to use the
395 medications of a similar drug class or for a similar medical
396 indication unless contraindicated in the Food and Drug
397 Administration labeling. The trial period between the specified
398 steps may vary according to the medical indication. The step
399 therapy approval process shall be developed in accordance with
400 the committee as stated in s. 409.91195(7) and (8). A drug
401 product may be approved without meeting the step-therapy prior
402 authorization criteria if the prescribing physician provides the
403 agency with additional written medical or clinical documentation
404 that the product is medically necessary because:
405 a. There is not a drug on the preferred drug list to treat
406 the disease or medical condition which is an acceptable clinical
407 alternative;
408 b. The alternatives have been ineffective in the treatment
409 of the beneficiary’s disease; or
410 c. Based on historic evidence and known characteristics of
411 the patient and the drug, the drug is likely to be ineffective,
412 or the number of doses have been ineffective.
413
414 The agency shall work with the physician to determine the best
415 alternative for the patient. The agency may adopt rules waiving
416 the requirements for written clinical documentation for specific
417 drugs in limited clinical situations.
418 16.17. The agency shall implement a return and reuse
419 program for drugs dispensed by pharmacies to institutional
420 recipients, which includes payment of a $5 restocking fee for
421 the implementation and operation of the program. The return and
422 reuse program shall be implemented electronically and in a
423 manner that promotes efficiency. The program must permit a
424 pharmacy to exclude drugs from the program if it is not
425 practical or cost-effective for the drug to be included and must
426 provide for the return to inventory of drugs that cannot be
427 credited or returned in a cost-effective manner. The agency
428 shall determine if the program has reduced the amount of
429 Medicaid prescription drugs that which are destroyed on an
430 annual basis and if there are additional ways to ensure more
431 prescription drugs are not destroyed which could safely be
432 reused.
433 Section 4. Subsections (1) and (2) of section 409.979,
434 Florida Statutes, are amended to read:
435 409.979 Eligibility.—
436 (1) PREREQUISITE CRITERIA FOR ELIGIBILITY.—Medicaid
437 recipients who meet all of the following criteria are eligible
438 to receive long-term care services and must receive long-term
439 care services by participating in the long-term care managed
440 care program. The recipient must be:
441 (a) Sixty-five years of age or older, or age 18 or older
442 and eligible for Medicaid by reason of a disability.
443 (b) Determined by the Comprehensive Assessment Review and
444 Evaluation for Long-Term Care Services (CARES) preadmission
445 screening program to require nursing facility care as defined in
446 s. 409.985(3) or, in the case of individuals diagnosed with
447 cystic fibrosis, determined by the CARES program to require
448 hospital-level of care.
449 (2) ENROLLMENT OFFERS.—
450 (a) Subject to the availability of funds, the Department of
451 Elderly Affairs shall make offers for enrollment to eligible
452 individuals based on a wait-list prioritization. Before making
453 enrollment offers, the agency and the Department of Elderly
454 Affairs shall determine that sufficient funds exist to support
455 additional enrollment into plans.
456 (b) Medicaid recipients enrolled in one of the following
457 home and community-based service Medicaid waivers are eligible
458 to participate in the long-term care managed care program when
459 all eligibility criteria requirements established in paragraph
460 (1) of this subsection are met and shall be transitioned into
461 the long-term care managed care program by January 1, 2018:
462 1. Traumatic Brain and Spinal Cord Injury Waiver.
463 2. Adult Cystic Fibrosis Waiver.
464 3. Project AIDS Care Waiver.
465
466 The agency shall seek federal approval to terminate the
467 Traumatic Brain and Spinal Cord Injury Waiver, the Adult Cystic
468 Fibrosis Waiver, and the Project AIDS Care Waiver after all
469 eligible Medicaid recipients have transitioned into the long
470 term care managed care program.
471 Section 5. Subsection (7) of section 393.0661, Florida
472 Statutes, is amended to read:
473 393.0661 Home and community-based services delivery system;
474 comprehensive redesign.—The Legislature finds that the home and
475 community-based services delivery system for persons with
476 developmental disabilities and the availability of appropriated
477 funds are two of the critical elements in making services
478 available. Therefore, it is the intent of the Legislature that
479 the Agency for Persons with Disabilities shall develop and
480 implement a comprehensive redesign of the system.
481 (7) The agency shall collect premiums or cost sharing
482 pursuant to s. 409.906(13)(c) s. 409.906(13)(d).
483 Section 6. Paragraph (a) of subsection (4) of section
484 409.968, Florida Statutes, is amended to read:
485 409.968 Managed care plan payments.—
486 (4)(a) Subject to a specific appropriation and federal
487 approval under s. 409.906(13)(d) s. 409.906(13)(e), the agency
488 shall establish a payment methodology to fund managed care plans
489 for flexible services for persons with severe mental illness and
490 substance use disorders, including, but not limited to,
491 temporary housing assistance. A managed care plan eligible for
492 these payments must do all of the following:
493 1. Participate as a specialty plan for severe mental
494 illness or substance use disorders or participate in counties
495 designated by the General Appropriations Act;
496 2. Include providers of behavioral health services pursuant
497 to chapters 394 and 397 in the managed care plan’s provider
498 network; and
499 3. Document a capability to provide housing assistance
500 through agreements with housing providers, relationships with
501 local housing coalitions, and other appropriate arrangements.
502 Section 7. This act shall take effect July 1, 2017.