House Bill hb1753e1
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HB 1753, First Engrossed
1 A bill to be entitled
2 An act relating to the Agency for Health Care
3 Administration; amending s. 409.8132, F.S.;
4 deleting the requirement to provide choice
5 counseling to eligible applicants under the
6 Medikids program component; amending s.
7 409.815, F.S.; correcting a cross reference;
8 amending s. 409.904, F.S.; revising Medicaid
9 eligibility requirements for certain elderly or
10 disabled persons; authorizing payment for
11 health insurance premiums of Medicaid-eligible
12 individuals under certain circumstances;
13 amending s. 409.905, F.S.; updating and
14 revising provisions relating to hospital
15 inpatient behavioral health services provided
16 pursuant to a federally approved waiver;
17 expanding provision of such services statewide;
18 amending s. 409.906, F.S.; deleting adult
19 denture services as optional Medicaid services
20 and restricting authorized hearing and visual
21 services to children; providing additional
22 requirements for authorized intermediate care
23 services; adding assistive care services as an
24 optional Medicaid service for certain
25 recipients; amending s. 409.9065, F.S.;
26 correcting a cross reference; amending s.
27 409.908, F.S.; providing for reimbursement of
28 hospital inpatient and outpatient services at
29 certain rates; permitting reimbursement for
30 certain Medicaid services based on competitive
31 bidding; deleting redundant provisions;
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HB 1753, First Engrossed
1 prohibiting increases in reimbursement rates to
2 nursing homes associated with changes in
3 ownership; precluding premium adjustments to
4 managed care organizations under certain
5 circumstances; revising provisions relating to
6 physician reimbursement and the reimbursement
7 fee schedule; deleting certain preferential
8 Medicaid payments for dually eligible
9 recipients; authorizing competitive procurement
10 of transportation services or the securing
11 through waivers of federal financing of
12 transportation services at certain rates;
13 correcting a cross reference; authorizing
14 public schools affiliated with Florida
15 universities to separately enroll in the
16 Medicaid certified school match program and
17 certify local expenditures; amending s.
18 409.911, F.S.; updating data requirements and
19 share rates for disproportionate share
20 distributions; amending s. 409.91195, F.S.;
21 revising provisions relating to the membership
22 of the Medicaid Pharmaceutical and Therapeutics
23 Committee; providing for development and
24 distribution of a restricted drug formulary for
25 Medicaid providers; amending s. 409.9116, F.S.;
26 modifying the formula for disproportionate
27 share/financial assistance distributions to
28 rural hospitals; amending s. 409.912, F.S.;
29 authorizing continued reimbursement of
30 substance abuse treatment services on a
31 fee-for-service basis under certain conditions;
2
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HB 1753, First Engrossed
1 expanding Medicaid managed care behavioral
2 health services statewide; deleting requirement
3 for choice counseling; deleting authorization
4 to test new marketing initiatives relating to
5 managed care options; deleting a restriction on
6 adjustment of capitation rates; permitting
7 competitive bidding for certain services;
8 modifying reimbursement to pharmacies;
9 permitting use of a restricted drug formulary,
10 authorizing exemptions therefrom, and
11 authorizing negotiation of supplemental rebates
12 from manufacturers pursuant thereto; requiring
13 prescriptions for Medicaid recipients to be on
14 certain standardized forms; amending s.
15 409.915, F.S.; increasing county contributions
16 to Medicaid for inpatient hospitalization;
17 exempting counties from contributing toward the
18 cost of inpatient services provided by certain
19 hospitals and for special Medicaid payments
20 under certain conditions; repealing s.
21 636.0145, F.S., relating to requirement for
22 licensure of certain entities contracting with
23 Medicaid to provide mental health care services
24 in certain counties pursuant to federal waiver,
25 to conform to changes made in this act;
26 providing a finding of important state
27 interest; providing an effective date.
28
29 Be It Enacted by the Legislature of the State of Florida:
30
31
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HB 1753, First Engrossed
1 Section 1. Subsection (7) of section 409.8132, Florida
2 Statutes, is amended to read:
3 409.8132 Medikids program component.--
4 (7) ENROLLMENT.--Enrollment in the Medikids program
5 component may only occur during periodic open enrollment
6 periods as specified by the agency. An applicant may apply for
7 enrollment in the Medikids program component and proceed
8 through the eligibility determination process at any time
9 throughout the year. However, enrollment in Medikids shall not
10 begin until the next open enrollment period; and a child may
11 not receive services under the Medikids program until the
12 child is enrolled in a managed care plan or MediPass. In
13 addition, Once determined eligible, an applicant may choose
14 receive choice counseling and select a managed care plan or
15 MediPass. The agency may initiate mandatory assignment for a
16 Medikids applicant who has not chosen a managed care plan or
17 MediPass provider after the applicant's voluntary choice
18 period ends. An applicant may select MediPass under the
19 Medikids program component only in counties that have fewer
20 than two managed care plans available to serve Medicaid
21 recipients and only if the federal Health Care Financing
22 Administration determines that MediPass constitutes "health
23 insurance coverage" as defined in Title XXI of the Social
24 Security Act.
25 Section 2. Paragraph (q) of subsection (2) of section
26 409.815, Florida Statutes, is amended to read:
27 409.815 Health benefits coverage; limitations.--
28 (2) BENCHMARK BENEFITS.--In order for health benefits
29 coverage to qualify for premium assistance payments for an
30 eligible child under ss. 409.810-409.820, the health benefits
31 coverage, except for coverage under Medicaid and Medikids,
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HB 1753, First Engrossed
1 must include the following minimum benefits, as medically
2 necessary.
3 (q) Dental services.--Subject to a specific
4 appropriation for this benefit, covered services include those
5 dental services provided to children by the Florida Medicaid
6 program under s. 409.906(5)(6).
7 Section 3. Subsection (1) of section 409.904, Florida
8 Statutes, is amended, and subsection (9) is added to said
9 section, to read:
10 409.904 Optional payments for eligible persons.--The
11 agency may make payments for medical assistance and related
12 services on behalf of the following persons who are determined
13 to be eligible subject to the income, assets, and categorical
14 eligibility tests set forth in federal and state law. Payment
15 on behalf of these Medicaid-eligible persons is subject to the
16 availability of moneys and any limitations established by the
17 General Appropriations Act or chapter 216.
18 (1) A person who is age 65 or older or is determined
19 to be disabled, whose income is at or below 90 100 percent of
20 federal poverty level, and whose assets do not exceed
21 established limitations.
22 (9) A Medicaid-eligible individual for the
23 individual's health insurance premiums, if the agency
24 determines that such payments are cost-effective.
25 Section 4. Subsection (5) of section 409.905, Florida
26 Statutes, is amended to read:
27 409.905 Mandatory Medicaid services.--The agency may
28 make payments for the following services, which are required
29 of the state by Title XIX of the Social Security Act,
30 furnished by Medicaid providers to recipients who are
31 determined to be eligible on the dates on which the services
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HB 1753, First Engrossed
1 were provided. Any service under this section shall be
2 provided only when medically necessary and in accordance with
3 state and federal law. Nothing in this section shall be
4 construed to prevent or limit the agency from adjusting fees,
5 reimbursement rates, lengths of stay, number of visits, number
6 of services, or any other adjustments necessary to comply with
7 the availability of moneys and any limitations or directions
8 provided for in the General Appropriations Act or chapter 216.
9 (5) HOSPITAL INPATIENT SERVICES.--The agency shall pay
10 for all covered services provided for the medical care and
11 treatment of a recipient who is admitted as an inpatient by a
12 licensed physician or dentist to a hospital licensed under
13 part I of chapter 395. However, the agency shall limit the
14 payment for inpatient hospital services for a Medicaid
15 recipient 21 years of age or older to 45 days or the number of
16 days necessary to comply with the General Appropriations Act.
17 (a) The agency is authorized to implement
18 reimbursement and utilization management reforms in order to
19 comply with any limitations or directions in the General
20 Appropriations Act, which may include, but are not limited to:
21 prior authorization for inpatient psychiatric days; prior
22 authorization for nonemergency hospital inpatient admissions;
23 enhanced utilization and concurrent review programs for highly
24 utilized services; reduction or elimination of covered days of
25 service; adjusting reimbursement ceilings for variable costs;
26 adjusting reimbursement ceilings for fixed and property costs;
27 and implementing target rates of increase.
28 (b) A licensed hospital maintained primarily for the
29 care and treatment of patients having mental disorders or
30 mental diseases is not eligible to participate in the hospital
31 inpatient portion of the Medicaid program except as provided
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HB 1753, First Engrossed
1 under in federal law or pursuant to a federally approved
2 waiver. However, the department shall apply for a waiver,
3 within 9 months after June 5, 1991, designed to provide
4 behavioral health hospitalization services for mental health
5 reasons to children and adults in the most cost-effective and
6 lowest cost setting possible. Such waiver shall include a
7 request for the opportunity to pay for care in hospitals known
8 under federal law as "institutions for mental disease" or
9 "IMD's." The behavioral health waiver proposal shall propose
10 no additional aggregate cost to the state or Federal
11 Government, and shall be conducted in Hillsborough County,
12 Highlands County, Hardee County, Manatee County, and Polk
13 County. Implementation of the behavioral health waiver
14 proposal shall not be the basis for adjusting a hospital's
15 Medicaid inpatient or outpatient rate. The waiver proposal may
16 incorporate competitive bidding for hospital services,
17 comprehensive brokering, prepaid capitated arrangements, or
18 other mechanisms deemed by the department to show promise in
19 reducing the cost of acute care and increasing the
20 effectiveness of preventive care. When developing The waiver
21 proposal, the department shall take into account price,
22 quality, accessibility, linkages of the hospital to community
23 services and family support programs, plans of the hospital to
24 ensure the earliest discharge possible, and the
25 comprehensiveness of the mental health and other health care
26 services offered by participating providers.
27 (c) The agency for Health Care Administration shall
28 adjust a hospital's current inpatient per diem rate to reflect
29 the cost of serving the Medicaid population at that
30 institution if:
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HB 1753, First Engrossed
1 1. The hospital experiences an increase in Medicaid
2 caseload by more than 25 percent in any year, primarily
3 resulting from the closure of a hospital in the same service
4 area occurring after July 1, 1995; or
5 2. The hospital's Medicaid per diem rate is at least
6 25 percent below the Medicaid per patient cost for that year.
7
8 No later than November 1, 2000, the agency must provide
9 estimated costs for any adjustment in a hospital inpatient per
10 diem pursuant to this paragraph to the Executive Office of the
11 Governor, the House of Representatives General Appropriations
12 Committee, and the Senate Budget Committee. Before the agency
13 implements a change in a hospital's inpatient per diem rate
14 pursuant to this paragraph, the Legislature must have
15 specifically appropriated sufficient funds in the 2001-2002
16 General Appropriations Act to support the increase in cost as
17 estimated by the agency. This paragraph is repealed on July 1,
18 2001.
19 Section 5. Section 409.906, Florida Statutes, is
20 amended to read:
21 409.906 Optional Medicaid services.--Subject to
22 specific appropriations, the agency may make payments for
23 services which are optional to the state under Title XIX of
24 the Social Security Act and are furnished by Medicaid
25 providers to recipients who are determined to be eligible on
26 the dates on which the services were provided. Any optional
27 service that is provided shall be provided only when medically
28 necessary and in accordance with state and federal law.
29 Nothing in this section shall be construed to prevent or limit
30 the agency from adjusting fees, reimbursement rates, lengths
31 of stay, number of visits, or number of services, or making
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HB 1753, First Engrossed
1 any other adjustments necessary to comply with the
2 availability of moneys and any limitations or directions
3 provided for in the General Appropriations Act or chapter 216.
4 If necessary to safeguard the state's systems of providing
5 services to elderly and disabled persons and subject to the
6 notice and review provisions of s. 216.177, the Governor may
7 direct the Agency for Health Care Administration to amend the
8 Medicaid state plan to delete the optional Medicaid service
9 known as "Intermediate Care Facilities for the Developmentally
10 Disabled." Optional services may include:
11 (1) ADULT DENTURE SERVICES.--The agency may pay for
12 dentures, the procedures required to seat dentures, and the
13 repair and reline of dentures, provided by or under the
14 direction of a licensed dentist, for a recipient who is age 21
15 or older.
16 (1)(2) ADULT HEALTH SCREENING SERVICES.--The agency
17 may pay for an annual routine physical examination, conducted
18 by or under the direction of a licensed physician, for a
19 recipient age 21 or older, without regard to medical
20 necessity, in order to detect and prevent disease, disability,
21 or other health condition or its progression.
22 (2)(3) AMBULATORY SURGICAL CENTER SERVICES.--The
23 agency may pay for services provided to a recipient in an
24 ambulatory surgical center licensed under part I of chapter
25 395, by or under the direction of a licensed physician or
26 dentist.
27 (3)(4) BIRTH CENTER SERVICES.--The agency may pay for
28 examinations and delivery, recovery, and newborn assessment,
29 and related services, provided in a licensed birth center
30 staffed with licensed physicians, certified nurse midwives,
31 and midwives licensed in accordance with chapter 467, to a
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HB 1753, First Engrossed
1 recipient expected to experience a low-risk pregnancy and
2 delivery.
3 (4)(5) CASE MANAGEMENT SERVICES.--The agency may pay
4 for primary care case management services rendered to a
5 recipient pursuant to a federally approved waiver, and
6 targeted case management services for specific groups of
7 targeted recipients, for which funding has been provided and
8 which are rendered pursuant to federal guidelines. The agency
9 is authorized to limit reimbursement for targeted case
10 management services in order to comply with any limitations or
11 directions provided for in the General Appropriations Act.
12 Notwithstanding s. 216.292, the Department of Children and
13 Family Services may transfer general funds to the Agency for
14 Health Care Administration to fund state match requirements
15 exceeding the amount specified in the General Appropriations
16 Act for targeted case management services.
17 (5)(6) CHILDREN'S DENTAL SERVICES.--The agency may pay
18 for diagnostic, preventive, or corrective procedures,
19 including orthodontia in severe cases, provided to a recipient
20 under age 21, by or under the supervision of a licensed
21 dentist. Services provided under this program include
22 treatment of the teeth and associated structures of the oral
23 cavity, as well as treatment of disease, injury, or impairment
24 that may affect the oral or general health of the individual.
25 (6)(7) CHIROPRACTIC SERVICES.--The agency may pay for
26 manual manipulation of the spine and initial services,
27 screening, and X rays provided to a recipient by a licensed
28 chiropractic physician.
29 (7)(8) COMMUNITY MENTAL HEALTH SERVICES.--The agency
30 may pay for rehabilitative services provided to a recipient by
31 a mental health or substance abuse provider licensed by the
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HB 1753, First Engrossed
1 agency and under contract with the agency or the Department of
2 Children and Family Services to provide such services. Those
3 services which are psychiatric in nature shall be rendered or
4 recommended by a psychiatrist, and those services which are
5 medical in nature shall be rendered or recommended by a
6 physician or psychiatrist. The agency must develop a provider
7 enrollment process for community mental health providers which
8 bases provider enrollment on an assessment of service need.
9 The provider enrollment process shall be designed to control
10 costs, prevent fraud and abuse, consider provider expertise
11 and capacity, and assess provider success in managing
12 utilization of care and measuring treatment outcomes.
13 Providers will be selected through a competitive procurement
14 or selective contracting process. In addition to other
15 community mental health providers, the agency shall consider
16 for enrollment mental health programs licensed under chapter
17 395 and group practices licensed under chapter 458, chapter
18 459, chapter 490, or chapter 491. The agency is also
19 authorized to continue operation of its behavioral health
20 utilization management program and may develop new services if
21 these actions are necessary to ensure savings from the
22 implementation of the utilization management system. The
23 agency shall coordinate the implementation of this enrollment
24 process with the Department of Children and Family Services
25 and the Department of Juvenile Justice. The agency is
26 authorized to utilize diagnostic criteria in setting
27 reimbursement rates, to preauthorize certain high-cost or
28 highly utilized services, to limit or eliminate coverage for
29 certain services, or to make any other adjustments necessary
30 to comply with any limitations or directions provided for in
31 the General Appropriations Act.
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HB 1753, First Engrossed
1 (8)(9) DIALYSIS FACILITY SERVICES.--Subject to
2 specific appropriations being provided for this purpose, the
3 agency may pay a dialysis facility that is approved as a
4 dialysis facility in accordance with Title XVIII of the Social
5 Security Act, for dialysis services that are provided to a
6 Medicaid recipient under the direction of a physician licensed
7 to practice medicine or osteopathic medicine in this state,
8 including dialysis services provided in the recipient's home
9 by a hospital-based or freestanding dialysis facility.
10 (9)(10) DURABLE MEDICAL EQUIPMENT.--The agency may
11 authorize and pay for certain durable medical equipment and
12 supplies provided to a Medicaid recipient as medically
13 necessary.
14 (10)(11) HEALTHY START SERVICES.--The agency may pay
15 for a continuum of risk-appropriate medical and psychosocial
16 services for the Healthy Start program in accordance with a
17 federal waiver. The agency may not implement the federal
18 waiver unless the waiver permits the state to limit enrollment
19 or the amount, duration, and scope of services to ensure that
20 expenditures will not exceed funds appropriated by the
21 Legislature or available from local sources. If the Health
22 Care Financing Administration does not approve a federal
23 waiver for Healthy Start services, the agency, in consultation
24 with the Department of Health and the Florida Association of
25 Healthy Start Coalitions, is authorized to establish a
26 Medicaid certified-match program for Healthy Start services.
27 Participation in the Healthy Start certified-match program
28 shall be voluntary, and reimbursement shall be limited to the
29 federal Medicaid share to Medicaid-enrolled Healthy Start
30 coalitions for services provided to Medicaid recipients. The
31 agency shall take no action to implement a certified-match
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HB 1753, First Engrossed
1 program without ensuring that the amendment and review
2 requirements of ss. 216.177 and 216.181 have been met.
3 (11)(12) HEARING SERVICES.--Except for individuals 21
4 years of age or older, the agency may pay for hearing and
5 related services, including hearing evaluations, hearing aid
6 devices, dispensing of the hearing aid, and related repairs,
7 if provided to a recipient by a licensed hearing aid
8 specialist, otolaryngologist, otologist, audiologist, or
9 physician.
10 (12)(13) HOME AND COMMUNITY-BASED SERVICES.--The
11 agency may pay for home-based or community-based services that
12 are rendered to a recipient in accordance with a federally
13 approved waiver program.
14 (13)(14) HOSPICE CARE SERVICES.--The agency may pay
15 for all reasonable and necessary services for the palliation
16 or management of a recipient's terminal illness, if the
17 services are provided by a hospice that is licensed under part
18 VI of chapter 400 and meets Medicare certification
19 requirements.
20 (14)(15) INTERMEDIATE CARE FACILITY FOR THE
21 DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for
22 health-related care and services provided on a 24-hour-a-day
23 basis by a facility licensed and certified as a Medicaid
24 Intermediate Care Facility for the Developmentally Disabled,
25 for a recipient who needs such care because of a developmental
26 disability.
27 (15)(16) INTERMEDIATE CARE SERVICES.--The agency may
28 pay for 24-hour-a-day intermediate care nursing and
29 rehabilitation services rendered to a recipient in a nursing
30 facility licensed under part II of chapter 400, if the
31 services are ordered by and provided under the direction of a
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HB 1753, First Engrossed
1 physician, meet nursing home level of care criteria as
2 determined by the Comprehensive Assessment and Review
3 Long-Term Care (CARE) Program of the Department of Elderly
4 Affairs, and do not meet the definition of "general care" as
5 used in the Medicaid budget estimating process.
6 (16)(17) OPTOMETRIC SERVICES.--The agency may pay for
7 services provided to a recipient, including examination,
8 diagnosis, treatment, and management, related to ocular
9 pathology, if the services are provided by a licensed
10 optometrist or physician.
11 (17)(18) PHYSICIAN ASSISTANT SERVICES.--The agency may
12 pay for all services provided to a recipient by a physician
13 assistant licensed under s. 458.347 or s. 459.022.
14 Reimbursement for such services must be not less than 80
15 percent of the reimbursement that would be paid to a physician
16 who provided the same services.
17 (18)(19) PODIATRIC SERVICES.--The agency may pay for
18 services, including diagnosis and medical, surgical,
19 palliative, and mechanical treatment, related to ailments of
20 the human foot and lower leg, if provided to a recipient by a
21 podiatric physician licensed under state law.
22 (19)(20) PRESCRIBED DRUG SERVICES.--The agency may pay
23 for medications that are prescribed for a recipient by a
24 physician or other licensed practitioner of the healing arts
25 authorized to prescribe medications and that are dispensed to
26 the recipient by a licensed pharmacist or physician in
27 accordance with applicable state and federal law.
28 (20)(21) REGISTERED NURSE FIRST ASSISTANT
29 SERVICES.--The agency may pay for all services provided to a
30 recipient by a registered nurse first assistant as described
31 in s. 464.027. Reimbursement for such services may not be
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HB 1753, First Engrossed
1 less than 80 percent of the reimbursement that would be paid
2 to a physician providing the same services.
3 (21)(22) STATE HOSPITAL SERVICES.--The agency may pay
4 for all-inclusive psychiatric inpatient hospital care provided
5 to a recipient age 65 or older in a state mental hospital.
6 (22)(23) VISUAL SERVICES.--Except for individuals 21
7 years of age or older, the agency may pay for visual
8 examinations, eyeglasses, and eyeglass repairs for a
9 recipient, if they are prescribed by a licensed physician
10 specializing in diseases of the eye or by a licensed
11 optometrist.
12 (23)(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.--The
13 Agency for Health Care Administration, in consultation with
14 the Department of Children and Family Services, may establish
15 a targeted case-management pilot project in those counties
16 identified by the Department of Children and Family Services
17 and for the community-based child welfare project in Sarasota
18 and Manatee counties, as authorized under s. 409.1671. These
19 projects shall be established for the purpose of determining
20 the impact of targeted case management on the child welfare
21 program and the earnings from the child welfare program.
22 Results of the pilot projects shall be reported to the Child
23 Welfare Estimating Conference and the Social Services
24 Estimating Conference established under s. 216.136. The number
25 of projects may not be increased until requested by the
26 Department of Children and Family Services, recommended by the
27 Child Welfare Estimating Conference and the Social Services
28 Estimating Conference, and approved by the Legislature. The
29 covered group of individuals who are eligible to receive
30 targeted case management include children who are eligible for
31 Medicaid; who are between the ages of birth through 21; and
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HB 1753, First Engrossed
1 who are under protective supervision or postplacement
2 supervision, under foster-care supervision, or in shelter care
3 or foster care. The number of individuals who are eligible to
4 receive targeted case management shall be limited to the
5 number for whom the Department of Children and Family Services
6 has available matching funds to cover the costs. The general
7 revenue funds required to match the funds for services
8 provided by the community-based child welfare projects are
9 limited to funds available for services described under s.
10 409.1671. The Department of Children and Family Services may
11 transfer the general revenue matching funds as billed by the
12 Agency for Health Care Administration.
13 (24) ASSISTIVE CARE SERVICES.--The agency may pay for
14 assistive care services provided to recipients with functional
15 or cognitive impairments residing in assisted living
16 facilities, adult family-care homes, or residential treatment
17 facilities with 16 or fewer beds. These services may include
18 health support, assistance with the activities of daily living
19 and the instrumental acts of daily living, assistance with
20 medication administration, and arrangements for health care.
21 Section 6. Subsection (3) of section 409.9065, Florida
22 Statutes, is amended to read:
23 409.9065 Pharmaceutical expense assistance.--
24 (3) BENEFITS.--Medications covered under the
25 pharmaceutical expense assistance program are those covered
26 under the Medicaid program in s. 409.906(19)(20). Monthly
27 benefit payments shall be limited to $80 per program
28 participant. Participants are required to make a 10-percent
29 coinsurance payment for each prescription purchased through
30 this program.
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1 Section 7. Section 409.908, Florida Statutes, is
2 amended to read:
3 409.908 Reimbursement of Medicaid providers.--Subject
4 to specific appropriations, the agency shall reimburse
5 Medicaid providers, in accordance with state and federal law,
6 according to methodologies set forth in the rules of the
7 agency and in policy manuals and handbooks incorporated by
8 reference therein. These methodologies may include fee
9 schedules, reimbursement methods based on cost reporting,
10 negotiated fees, competitive bidding pursuant to s. 287.057,
11 and other mechanisms the agency considers efficient and
12 effective for purchasing services or goods on behalf of
13 recipients. Payment for Medicaid compensable services made on
14 behalf of Medicaid eligible persons is subject to the
15 availability of moneys and any limitations or directions
16 provided for in the General Appropriations Act or chapter 216.
17 Further, nothing in this section shall be construed to prevent
18 or limit the agency from adjusting fees, reimbursement rates,
19 lengths of stay, number of visits, or number of services, or
20 making any other adjustments necessary to comply with the
21 availability of moneys and any limitations or directions
22 provided for in the General Appropriations Act, provided the
23 adjustment is consistent with legislative intent.
24 (1) Reimbursement to hospitals licensed under part I
25 of chapter 395 must be made prospectively or on the basis of
26 negotiation or competitive bidding. The agency shall reimburse
27 for hospital inpatient and outpatient services under this
28 subsection at rates no greater than 95 percent of the
29 reimbursement rates in effect for the 2000-2001 state fiscal
30 year.
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1 (a) Reimbursement for inpatient care is limited as
2 provided for in s. 409.905(5), except for:
3 1. The raising of rate reimbursement caps, excluding
4 rural hospitals.
5 2. Recognition of the costs of graduate medical
6 education.
7 3. Other methodologies recognized in the General
8 Appropriations Act.
9
10 During the years funds are transferred from the Board of
11 Regents, any reimbursement supported by such funds shall be
12 subject to certification by the Board of Regents that the
13 hospital has complied with s. 381.0403. The agency is
14 authorized to receive funds from state entities, including,
15 but not limited to, the Board of Regents, local governments,
16 and other local political subdivisions, for the purpose of
17 making special exception payments, including federal matching
18 funds, through the Medicaid inpatient reimbursement
19 methodologies. Funds received from state entities or local
20 governments for this purpose shall be separately accounted for
21 and shall not be commingled with other state or local funds in
22 any manner. Notwithstanding this section and s. 409.915,
23 counties are exempt from contributing toward the cost of the
24 special exception reimbursement for hospitals serving a
25 disproportionate share of low-income persons and providing
26 graduate medical education.
27 (b) Reimbursement for hospital outpatient care is
28 limited to $1,500 per state fiscal year per recipient, except
29 for:
30
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1 1. Such care provided to a Medicaid recipient under
2 age 21, in which case the only limitation is medical
3 necessity.
4 2. Renal dialysis services.
5 3. Other exceptions made by the agency.
6
7 The agency is authorized to receive funds from state entities,
8 including, but not limited to, the Board of Regents, local
9 governments, and other local political subdivisions, for the
10 purpose of making payments, including federal matching funds,
11 through the Medicaid outpatient reimbursement methodologies.
12 Funds received from state entities and local governments for
13 this purpose shall be separately accounted for and shall not
14 be commingled with other state or local funds in any manner.
15 (c) Hospitals that provide services to a
16 disproportionate share of low-income Medicaid recipients, or
17 that participate in the regional perinatal intensive care
18 center program under chapter 383, or that participate in the
19 statutory teaching hospital disproportionate share program may
20 receive additional reimbursement. The total amount of payment
21 for disproportionate share hospitals shall be fixed by the
22 General Appropriations Act. The computation of these payments
23 must be made in compliance with all federal regulations and
24 the methodologies described in ss. 409.911, 409.9112, and
25 409.9113.
26 (d) The agency is authorized to limit inflationary
27 increases for outpatient hospital services as directed by the
28 General Appropriations Act.
29 (2)(a)1. Reimbursement to nursing homes licensed under
30 part II of chapter 400 and state-owned-and-operated
31 intermediate care facilities for the developmentally disabled
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HB 1753, First Engrossed
1 licensed under chapter 393 must be made prospectively or on
2 the basis of competitive bidding.
3 2. Unless otherwise limited or directed in the General
4 Appropriations Act, reimbursement to hospitals licensed under
5 part I of chapter 395 for the provision of swing-bed nursing
6 home services must be made on the basis of the average
7 statewide nursing home payment, and reimbursement to a
8 hospital licensed under part I of chapter 395 for the
9 provision of skilled nursing services must be made on the
10 basis of the average nursing home payment for those services
11 in the county in which the hospital is located. When a
12 hospital is located in a county that does not have any
13 community nursing homes, reimbursement must be determined by
14 averaging the nursing home payments, in counties that surround
15 the county in which the hospital is located. Reimbursement to
16 hospitals, including Medicaid payment of Medicare copayments,
17 for skilled nursing services shall be limited to 30 days,
18 unless a prior authorization has been obtained from the
19 agency. Medicaid reimbursement may be extended by the agency
20 beyond 30 days, and approval must be based upon verification
21 by the patient's physician that the patient requires
22 short-term rehabilitative and recuperative services only, in
23 which case an extension of no more than 15 days may be
24 approved. Reimbursement to a hospital licensed under part I of
25 chapter 395 for the temporary provision of skilled nursing
26 services to nursing home residents who have been displaced as
27 the result of a natural disaster or other emergency may not
28 exceed the average county nursing home payment for those
29 services in the county in which the hospital is located and is
30 limited to the period of time which the agency considers
31
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HB 1753, First Engrossed
1 necessary for continued placement of the nursing home
2 residents in the hospital.
3 (b) Subject to any limitations or directions provided
4 for in the General Appropriations Act, the agency shall
5 establish and implement a Florida Title XIX Long-Term Care
6 Reimbursement Plan (Medicaid) for nursing home care in order
7 to provide care and services in conformance with the
8 applicable state and federal laws, rules, regulations, and
9 quality and safety standards and to ensure that individuals
10 eligible for medical assistance have reasonable geographic
11 access to such care. The agency shall not provide for any
12 increases in reimbursement rates to nursing homes associated
13 with changes in ownership. Under the plan, interim rate
14 adjustments shall not be granted to reflect increases in the
15 cost of general or professional liability insurance for
16 nursing homes unless the following criteria are met: have at
17 least a 65 percent Medicaid utilization in the most recent
18 cost report submitted to the agency, and the increase in
19 general or professional liability costs to the facility for
20 the most recent policy period affects the total Medicaid per
21 diem by at least 5 percent. This rate adjustment shall not
22 result in the per diem exceeding the class ceiling. This
23 provision shall apply only to fiscal year 2000-2001 and shall
24 be implemented to the extent existing appropriations are
25 available. The agency shall report to the Governor, the
26 Speaker of the House of Representatives, and the President of
27 the Senate by December 31, 2000, on the cost of liability
28 insurance for Florida nursing homes for fiscal years 1999 and
29 2000 and the extent to which these costs are not being
30 compensated by the Medicaid program. Medicaid-participating
31 nursing homes shall be required to report to the agency
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HB 1753, First Engrossed
1 information necessary to compile this report. Effective no
2 earlier than the rate-setting period beginning April 1, 1999,
3 the agency shall establish a case-mix reimbursement
4 methodology for the rate of payment for long-term care
5 services for nursing home residents. The agency shall compute
6 a per diem rate for Medicaid residents, adjusted for case mix,
7 which is based on a resident classification system that
8 accounts for the relative resource utilization by different
9 types of residents and which is based on level-of-care data
10 and other appropriate data. The case-mix methodology developed
11 by the agency shall take into account the medical, behavioral,
12 and cognitive deficits of residents. In developing the
13 reimbursement methodology, the agency shall evaluate and
14 modify other aspects of the reimbursement plan as necessary to
15 improve the overall effectiveness of the plan with respect to
16 the costs of patient care, operating costs, and property
17 costs. In the event adequate data are not available, the
18 agency is authorized to adjust the patient's care component or
19 the per diem rate to more adequately cover the cost of
20 services provided in the patient's care component. The agency
21 shall work with the Department of Elderly Affairs, the Florida
22 Health Care Association, and the Florida Association of Homes
23 for the Aging in developing the methodology. It is the intent
24 of the Legislature that the reimbursement plan achieve the
25 goal of providing access to health care for nursing home
26 residents who require large amounts of care while encouraging
27 diversion services as an alternative to nursing home care for
28 residents who can be served within the community. The agency
29 shall base the establishment of any maximum rate of payment,
30 whether overall or component, on the available moneys as
31 provided for in the General Appropriations Act. The agency may
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HB 1753, First Engrossed
1 base the maximum rate of payment on the results of
2 scientifically valid analysis and conclusions derived from
3 objective statistical data pertinent to the particular maximum
4 rate of payment.
5 (3) Subject to any limitations or directions provided
6 for in the General Appropriations Act, the following Medicaid
7 services and goods may be reimbursed on a fee-for-service
8 basis. For each allowable service or goods furnished in
9 accordance with Medicaid rules, policy manuals, handbooks, and
10 state and federal law, the payment shall be the amount billed
11 by the provider, the provider's usual and customary charge, or
12 the maximum allowable fee established by the agency, whichever
13 amount is less, with the exception of those services or goods
14 for which the agency makes payment using a methodology based
15 on capitation rates, average costs, or negotiated fees, or
16 competitive bidding. Before the agency implements competitive
17 bidding for any Medicaid service, the Legislature must
18 specifically authorize the change in reimbursement methodology
19 for that service in the General Appropriations Act.
20 (a) Advanced registered nurse practitioner services.
21 (b) Birth center services.
22 (c) Chiropractic services.
23 (d) Community mental health services.
24 (e) Dental services, including oral and maxillofacial
25 surgery.
26 (f) Durable medical equipment.
27 (g) Hearing services for Medicaid recipients under age
28 21.
29 (h) Occupational therapy for Medicaid recipients under
30 age 21.
31 (i) Optometric services.
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HB 1753, First Engrossed
1 (j) Orthodontic services.
2 (k) Personal care for Medicaid recipients under age
3 21.
4 (l) Physical therapy for Medicaid recipients under age
5 21.
6 (m) Physician assistant services.
7 (n) Podiatric services.
8 (o) Portable X-ray services.
9 (p) Private-duty nursing for Medicaid recipients under
10 age 21.
11 (q) Registered nurse first assistant services.
12 (r) Respiratory therapy for Medicaid recipients under
13 age 21.
14 (s) Speech therapy for Medicaid recipients under age
15 21.
16 (t) Visual services for Medicaid recipients under age
17 21.
18 (4) Subject to any limitations or directions provided
19 for in the General Appropriations Act, alternative health
20 plans, health maintenance organizations, and prepaid health
21 plans shall be reimbursed a fixed, prepaid amount negotiated,
22 or competitively bid pursuant to s. 287.057, by the agency and
23 prospectively paid to the provider monthly for each Medicaid
24 recipient enrolled. The amount may not exceed the average
25 amount the agency determines it would have paid, based on
26 claims experience, for recipients in the same or similar
27 category of eligibility. The agency shall calculate
28 capitation rates on a regional basis and, beginning September
29 1, 1995, shall include age-band differentials in such
30 calculations. Effective July 1, 2001, the cost of exempting
31 statutory teaching hospitals, specialty hospitals, and
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HB 1753, First Engrossed
1 community hospital education program hospitals from
2 reimbursement ceilings and the cost of special Medicaid
3 payments shall not be included in premiums paid to health
4 maintenance organizations or prepaid health care plans.
5 (5) An ambulatory surgical center shall be reimbursed
6 the lesser of the amount billed by the provider or the
7 Medicare-established allowable amount for the facility.
8 (6) A provider of early and periodic screening,
9 diagnosis, and treatment services to Medicaid recipients who
10 are children under age 21 shall be reimbursed using an
11 all-inclusive rate stipulated in a fee schedule established by
12 the agency. A provider of the visual, dental, and hearing
13 components of such services shall be reimbursed the lesser of
14 the amount billed by the provider or the Medicaid maximum
15 allowable fee established by the agency.
16 (7) A provider of family planning services shall be
17 reimbursed the lesser of the amount billed by the provider or
18 an all-inclusive amount per type of visit for physicians and
19 advanced registered nurse practitioners, as established by the
20 agency in a fee schedule.
21 (8) A provider of home-based or community-based
22 services rendered pursuant to a federally approved waiver
23 shall be reimbursed based on an established or negotiated rate
24 for each service. These rates shall be established according
25 to an analysis of the expenditure history and prospective
26 budget developed by each contract provider participating in
27 the waiver program, or under any other methodology adopted by
28 the agency and approved by the Federal Government in
29 accordance with the waiver. Effective July 1, 1996, privately
30 owned and operated community-based residential facilities
31 which meet agency requirements and which formerly received
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HB 1753, First Engrossed
1 Medicaid reimbursement for the optional intermediate care
2 facility for the mentally retarded service may participate in
3 the developmental services waiver as part of a
4 home-and-community-based continuum of care for Medicaid
5 recipients who receive waiver services.
6 (9) A provider of home health care services or of
7 medical supplies and appliances shall be reimbursed on the
8 basis of competitive bidding or for the lesser of the amount
9 billed by the provider or the agency's established maximum
10 allowable amount, except that, in the case of the rental of
11 durable medical equipment, the total rental payments may not
12 exceed the purchase price of the equipment over its expected
13 useful life or the agency's established maximum allowable
14 amount, whichever amount is less.
15 (10) A hospice shall be reimbursed through a
16 prospective system for each Medicaid hospice patient at
17 Medicaid rates using the methodology established for hospice
18 reimbursement pursuant to Title XVIII of the federal Social
19 Security Act.
20 (11) A provider of independent laboratory services
21 shall be reimbursed on the basis of competitive bidding or for
22 the least of the amount billed by the provider, the provider's
23 usual and customary charge, or the Medicaid maximum allowable
24 fee established by the agency.
25 (12)(a) A physician shall be reimbursed the lesser of
26 the amount billed by the provider or the Medicaid maximum
27 allowable fee established by the agency.
28 (b) The agency shall adopt a fee schedule, subject to
29 any limitations or directions provided for in the General
30 Appropriations Act, based on a resource-based relative value
31 scale for pricing Medicaid physician services. Under this fee
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HB 1753, First Engrossed
1 schedule, physicians shall be paid a dollar amount for each
2 service based on the average resources required to provide the
3 service, including, but not limited to, estimates of average
4 physician time and effort, practice expense, and the costs of
5 professional liability insurance. The fee schedule shall
6 provide increased reimbursement for preventive and primary
7 care services and lowered reimbursement for specialty services
8 by using at least two conversion factors, one for cognitive
9 services and another for procedural services. The fee
10 schedule shall not increase total Medicaid physician
11 expenditures unless funds are specifically provided for such
12 increase. However, in no case may any increase result in
13 physicians being paid more than the Medicare fee moneys are
14 available, and shall be phased in over a 2-year period
15 beginning on July 1, 1994. The Agency for Health Care
16 Administration shall seek the advice of a 16-member advisory
17 panel in formulating and adopting the fee schedule. The panel
18 shall consist of Medicaid physicians licensed under chapters
19 458 and 459 and shall be composed of 50 percent primary care
20 physicians and 50 percent specialty care physicians.
21 (c) Notwithstanding paragraph (b), reimbursement fees
22 to physicians for providing total obstetrical services to
23 Medicaid recipients, which include prenatal, delivery, and
24 postpartum care, shall be at least $1,500 per delivery for a
25 pregnant woman with low medical risk and at least $2,000 per
26 delivery for a pregnant woman with high medical risk. However,
27 reimbursement to physicians working in Regional Perinatal
28 Intensive Care Centers designated pursuant to chapter 383, for
29 services to certain pregnant Medicaid recipients with a high
30 medical risk, may be made according to obstetrical care and
31 neonatal care groupings and rates established by the agency.
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HB 1753, First Engrossed
1 Nurse midwives licensed under part I of chapter 464 or
2 midwives licensed under chapter 467 shall be reimbursed at no
3 less than 80 percent of the low medical risk fee. The agency
4 shall by rule determine, for the purpose of this paragraph,
5 what constitutes a high or low medical risk pregnant woman and
6 shall not pay more based solely on the fact that a caesarean
7 section was performed, rather than a vaginal delivery. The
8 agency shall by rule determine a prorated payment for
9 obstetrical services in cases where only part of the total
10 prenatal, delivery, or postpartum care was performed. The
11 Department of Health shall adopt rules for appropriate
12 insurance coverage for midwives licensed under chapter 467.
13 Prior to the issuance and renewal of an active license, or
14 reactivation of an inactive license for midwives licensed
15 under chapter 467, such licensees shall submit proof of
16 coverage with each application.
17 (13) Medicare premiums for persons eligible for both
18 Medicare and Medicaid coverage shall be paid at the rates
19 established by Title XVIII of the Social Security Act. For
20 Medicare services rendered to Medicaid-eligible persons,
21 Medicaid shall pay Medicare deductibles and coinsurance as
22 follows:
23 (a) Medicaid shall make no payment toward deductibles
24 and coinsurance for any service that is not covered by
25 Medicaid.
26 (b) Medicaid's financial obligation for deductibles
27 and coinsurance payments shall be based on Medicare allowable
28 fees, not on a provider's billed charges.
29 (c) Medicaid will pay no portion of Medicare
30 deductibles and coinsurance when payment that Medicare has
31 made for the service equals or exceeds what Medicaid would
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HB 1753, First Engrossed
1 have paid if it had been the sole payor. The combined payment
2 of Medicare and Medicaid shall not exceed the amount Medicaid
3 would have paid had it been the sole payor. The Legislature
4 finds that there has been confusion regarding the
5 reimbursement for services rendered to dually eligible
6 Medicare beneficiaries. Accordingly, the Legislature clarifies
7 that it has always been the intent of the Legislature before
8 and after 1991 that, in reimbursing in accordance with fees
9 established by Title XVIII for premiums, deductibles, and
10 coinsurance for Medicare services rendered by physicians to
11 Medicaid eligible persons, physicians be reimbursed at the
12 lesser of the amount billed by the physician or the Medicaid
13 maximum allowable fee established by the Agency for Health
14 Care Administration, as is permitted by federal law. It has
15 never been the intent of the Legislature with regard to such
16 services rendered by physicians that Medicaid be required to
17 provide any payment for deductibles, coinsurance, or
18 copayments for Medicare cost sharing, or any expenses incurred
19 relating thereto, in excess of the payment amount provided for
20 under the State Medicaid plan for such service. This payment
21 methodology is applicable even in those situations in which
22 the payment for Medicare cost sharing for a qualified Medicare
23 beneficiary with respect to an item or service is reduced or
24 eliminated. This expression of the Legislature is in
25 clarification of existing law and shall apply to payment for,
26 and with respect to provider agreements with respect to, items
27 or services furnished on or after the effective date of this
28 act. This paragraph applies to payment by Medicaid for items
29 and services furnished before the effective date of this act
30 if such payment is the subject of a lawsuit that is based on
31
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HB 1753, First Engrossed
1 the provisions of this section, and that is pending as of, or
2 is initiated after, the effective date of this act.
3 (d) Notwithstanding The following provisions are
4 exceptions to paragraphs (a)-(c):
5 1. Medicaid payments for Nursing Home Medicare part A
6 coinsurance shall be the lesser of the Medicare coinsurance
7 amount or the Medicaid nursing home per diem rate.
8 2. Medicaid shall pay all deductibles and coinsurance
9 for Nursing Home Medicare part B services.
10 2.3. Medicaid shall pay all deductibles and
11 coinsurance for Medicare-eligible recipients receiving
12 freestanding end stage renal dialysis center services.
13 4. Medicaid shall pay all deductibles and coinsurance
14 for hospital outpatient Medicare part B services.
15 3.5. Medicaid payments for general hospital inpatient
16 services shall be limited to the Medicare deductible per spell
17 of illness. Medicaid shall make no payment toward coinsurance
18 for Medicare general hospital inpatient services.
19 4.6. Medicaid shall pay all deductibles and
20 coinsurance for Medicare emergency transportation services
21 provided by ambulances licensed pursuant to chapter 401.
22 (14) A provider of prescribed drugs shall be
23 reimbursed on the basis of competitive bidding or for the
24 least of the amount billed by the provider, the provider's
25 usual and customary charge, or the Medicaid maximum allowable
26 fee established by the agency, plus a dispensing fee. The
27 agency is directed to implement a variable dispensing fee for
28 payments for prescribed medicines while ensuring continued
29 access for Medicaid recipients. The variable dispensing fee
30 may be based upon, but not limited to, either or both the
31 volume of prescriptions dispensed by a specific pharmacy
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HB 1753, First Engrossed
1 provider and the volume of prescriptions dispensed to an
2 individual recipient. The agency is authorized to limit
3 reimbursement for prescribed medicine in order to comply with
4 any limitations or directions provided for in the General
5 Appropriations Act, which may include implementing a
6 prospective or concurrent utilization review program.
7 (15) A provider of primary care case management
8 services rendered pursuant to a federally approved waiver
9 shall be reimbursed by payment of a fixed, prepaid monthly sum
10 for each Medicaid recipient enrolled with the provider.
11 (16) A provider of rural health clinic services and
12 federally qualified health center services shall be reimbursed
13 a rate per visit based on total reasonable costs of the
14 clinic, as determined by the agency in accordance with federal
15 regulations.
16 (17) A provider of targeted case management services
17 shall be reimbursed pursuant to an established fee, except
18 where the Federal Government requires a public provider be
19 reimbursed on the basis of average actual costs.
20 (18) Unless otherwise provided for in the General
21 Appropriations Act, a provider of transportation services
22 shall be reimbursed the lesser of the amount billed by the
23 provider or the Medicaid maximum allowable fee established by
24 the agency, except when the agency has entered into a direct
25 contract with the provider, or with a community transportation
26 coordinator, for the provision of an all-inclusive service, or
27 when services are provided pursuant to an agreement negotiated
28 between the agency and the provider. The agency, as provided
29 for in s. 427.0135, shall purchase transportation services
30 through the community coordinated transportation system, if
31 available, unless the agency determines a more cost-effective
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HB 1753, First Engrossed
1 method for Medicaid clients. Nothing in this subsection shall
2 be construed to limit or preclude the agency from contracting
3 for services using a prepaid capitation rate or from
4 establishing maximum fee schedules, individualized
5 reimbursement policies by provider type, negotiated fees,
6 prior authorization, competitive bidding, increased use of
7 mass transit, or any other mechanism that the agency considers
8 efficient and effective for the purchase of services on behalf
9 of Medicaid clients, including implementing a transportation
10 eligibility process. The agency shall not be required to
11 contract with any community transportation coordinator or
12 transportation operator that has been determined by the
13 agency, the Department of Legal Affairs Medicaid Fraud Control
14 Unit, or any other state or federal agency to have engaged in
15 any abusive or fraudulent billing activities. The agency is
16 authorized to competitively procure transportation services or
17 make other changes necessary to secure approval of federal
18 waivers needed to permit federal financing of Medicaid
19 transportation services at the service matching rate rather
20 than the administrative matching rate.
21 (19) County health department services may be
22 reimbursed a rate per visit based on total reasonable costs of
23 the clinic, as determined by the agency in accordance with
24 federal regulations under the authority of 42 C.F.R. s.
25 431.615.
26 (20) A renal dialysis facility that provides dialysis
27 services under s. 409.906(8)(9) must be reimbursed the lesser
28 of the amount billed by the provider, the provider's usual and
29 customary charge, or the maximum allowable fee established by
30 the agency, whichever amount is less.
31
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HB 1753, First Engrossed
1 (21) The agency shall reimburse school districts which
2 certify the state match pursuant to ss. 236.0812 and 409.9071
3 for the federal portion of the school district's allowable
4 costs to deliver the services, based on the reimbursement
5 schedule. The school district shall determine the costs for
6 delivering services as authorized in ss. 236.0812 and 409.9071
7 for which the state match will be certified. Reimbursement of
8 school-based providers is contingent on such providers being
9 enrolled as Medicaid providers and meeting the qualifications
10 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
11 the federal Health Care Financing Administration. Speech
12 therapy providers who are certified through the Department of
13 Education pursuant to rule 6A-4.0176, Florida Administrative
14 Code, are eligible for reimbursement for services that are
15 provided on school premises. Any employee of the school
16 district who has been fingerprinted and has received a
17 criminal background check in accordance with Department of
18 Education rules and guidelines shall be exempt from any agency
19 requirements relating to criminal background checks.
20 Elementary, middle, and secondary schools affiliated with
21 Florida universities may separately enroll in the Medicaid
22 certified school match program and may certify local
23 expenditures for Medicaid school health services and the
24 administrative claiming program.
25 (22) Reimbursement to state-owned-and-operated
26 intermediate care facilities for the developmentally disabled
27 licensed under chapter 393 must be made prospectively.
28 Section 8. Paragraph (c) of subsection (1), paragraph
29 (b) of subsection (3), and subsection (7) of section 409.911,
30 Florida Statutes, are amended to read:
31
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HB 1753, First Engrossed
1 409.911 Disproportionate share program.--Subject to
2 specific allocations established within the General
3 Appropriations Act and any limitations established pursuant to
4 chapter 216, the agency shall distribute, pursuant to this
5 section, moneys to hospitals providing a disproportionate
6 share of Medicaid or charity care services by making quarterly
7 Medicaid payments as required. Notwithstanding the provisions
8 of s. 409.915, counties are exempt from contributing toward
9 the cost of this special reimbursement for hospitals serving a
10 disproportionate share of low-income patients.
11 (1) Definitions.--As used in this section and s.
12 409.9112:
13 (c) "Base Medicaid per diem" means the hospital's
14 Medicaid per diem rate initially established by the Agency for
15 Health Care Administration on January 1, 1999 prior to the
16 beginning of each state fiscal year. The base Medicaid per
17 diem rate shall not include any additional per diem increases
18 received as a result of the disproportionate share
19 distribution.
20 (3) In computing the disproportionate share rate:
21 (b) The agency shall use 1994 the most recent calendar
22 year audited financial data available at the beginning of each
23 state fiscal year for the calculation of disproportionate
24 share payments under this section.
25 (7) For fiscal year 1991-1992 and all years other than
26 1992-1993, The following criteria shall be used in determining
27 the disproportionate share percentage:
28 (a) If the disproportionate share rate is less than 10
29 percent, the disproportionate share percentage is zero and
30 there is no additional payment.
31
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HB 1753, First Engrossed
1 (b) If the disproportionate share rate is greater than
2 or equal to 10 percent, but less than 20 percent, then the
3 disproportionate share percentage is 1.8478498 2.1544347.
4 (c) If the disproportionate share rate is greater than
5 or equal to 20 percent, but less than 30 percent, then the
6 disproportionate share percentage is 3.4145488 4.6415888766.
7 (d) If the disproportionate share rate is greater than
8 or equal to 30 percent, but less than 40 percent, then the
9 disproportionate share percentage is 6.3095734 10.0000001388.
10 (e) If the disproportionate share rate is greater than
11 or equal to 40 percent, but less than 50 percent, then the
12 disproportionate share percentage is 11.6591440 21.544347299.
13 (f) If the disproportionate share rate is greater than
14 or equal to 50 percent, but less than 60 percent, then the
15 disproportionate share percentage is 73.5642254 46.41588941.
16 (g) If the disproportionate share rate is greater than
17 or equal to 60 percent but less than 72.5 percent, then the
18 disproportionate share percentage is 135.9356391 100.
19 (h) If the disproportionate share rate is greater than
20 or equal to 72.5 percent, then the disproportionate share
21 percentage is 170.
22 Section 9. Section 409.91195, Florida Statutes, is
23 amended to read:
24 409.91195 Medicaid Pharmaceutical and Therapeutics
25 Committee; restricted drug formulary.--There is created a
26 Medicaid Pharmaceutical and Therapeutics Committee for the
27 purpose of developing a restricted drug formulary. The
28 committee shall develop and implement a voluntary Medicaid
29 preferred prescribed drug designation program. The program
30 established under this section shall provide information to
31 Medicaid providers on medically appropriate and cost-efficient
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HB 1753, First Engrossed
1 prescription drug therapies through the development and
2 publication of a restricted drug formulary voluntary Medicaid
3 preferred prescribed-drug list.
4 (1) The Medicaid Pharmaceutical and Therapeutics
5 Committee shall be comprised of nine members as specified in
6 42 U.S.C. s. 1396 appointed as follows: one practicing
7 physician licensed under chapter 458, appointed by the Speaker
8 of the House of Representatives from a list of recommendations
9 from the Florida Medical Association; one practicing physician
10 licensed under chapter 459, appointed by the Speaker of the
11 House of Representatives from a list of recommendations from
12 the Florida Osteopathic Medical Association; one practicing
13 physician licensed under chapter 458, appointed by the
14 President of the Senate from a list of recommendations from
15 the Florida Academy of Family Physicians; one practicing
16 podiatric physician licensed under chapter 461, appointed by
17 the President of the Senate from a list of recommendations
18 from the Florida Podiatric Medical Association; one trauma
19 surgeon licensed under chapter 458, appointed by the Speaker
20 of the House of Representatives from a list of recommendations
21 from the American College of Surgeons; one practicing dentist
22 licensed under chapter 466, appointed by the President of the
23 Senate from a list of recommendations from the Florida Dental
24 Association; one practicing pharmacist licensed under chapter
25 465, appointed by the Governor from a list of recommendations
26 from the Florida Pharmacy Association; one practicing
27 pharmacist licensed under chapter 465, appointed by the
28 Governor from a list of recommendations from the Florida
29 Society of Health System Pharmacists; and one health care
30 professional with expertise in clinical pharmacology appointed
31 by the Governor from a list of recommendations from the
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HB 1753, First Engrossed
1 Pharmaceutical Research and Manufacturers Association. The
2 members shall be appointed to serve for terms of 2 years from
3 the date of their appointment. Members may be appointed to
4 more than one term. The Agency for Health Care Administration
5 shall serve as staff for the committee and assist them with
6 all ministerial duties.
7 (2) With the advice of Upon recommendation by the
8 committee, the Agency for Health Care Administration shall
9 establish a restricted drug formulary the voluntary Medicaid
10 preferred prescribed-drug list. Upon further recommendation by
11 the committee, the agency shall add to, delete from, or modify
12 the list. The committee shall also review requests for
13 additions to, deletions from, or modifications of the
14 formulary as presented to it by the agency; and, upon further
15 recommendation by the committee, the agency shall add to,
16 delete from, or modify the formulary as appropriate list. The
17 list shall be adopted by the committee in consultation with
18 medical specialists, when appropriate, using the following
19 criteria: use of the list shall be voluntary by providers and
20 the list must provide for medically appropriate drug therapies
21 for Medicaid patients which achieve cost savings in the
22 Medicaid program.
23 (3) The Agency for Health Care Administration shall
24 publish and disseminate the restricted drug formulary
25 voluntary Medicaid preferred prescribed drug list to all
26 Medicaid prescribing providers in the state.
27 Section 10. Subsection (2) of section 409.9116,
28 Florida Statutes, is amended to read:
29 409.9116 Disproportionate share/financial assistance
30 program for rural hospitals.--In addition to the payments made
31 under s. 409.911, the Agency for Health Care Administration
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HB 1753, First Engrossed
1 shall administer a federally matched disproportionate share
2 program and a state-funded financial assistance program for
3 statutory rural hospitals. The agency shall make
4 disproportionate share payments to statutory rural hospitals
5 that qualify for such payments and financial assistance
6 payments to statutory rural hospitals that do not qualify for
7 disproportionate share payments. The disproportionate share
8 program payments shall be limited by and conform with federal
9 requirements. Funds shall be distributed quarterly in each
10 fiscal year for which an appropriation is made.
11 Notwithstanding the provisions of s. 409.915, counties are
12 exempt from contributing toward the cost of this special
13 reimbursement for hospitals serving a disproportionate share
14 of low-income patients.
15 (2) The agency shall use the following formula for
16 distribution of funds for the disproportionate share/financial
17 assistance program for rural hospitals:
18 (a) The agency shall first determine a preliminary
19 payment amount for each rural hospital by allocating all
20 available state funds using the following formula:
21
22 PDAER = (TAERH x TARH)/STAERH
23
24 Where:
25 PDAER = preliminary distribution amount for each rural
26 hospital.
27 TAERH = total amount earned by each rural hospital.
28 TARH = total amount appropriated or distributed under
29 this section.
30 STAERH = sum of total amount earned by each rural
31 hospital.
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HB 1753, First Engrossed
1 (b) Federal matching funds for the disproportionate
2 share program shall then be calculated for those hospitals
3 that qualify for disproportionate share in paragraph (a).
4 (c) The state-funds-only payment amount shall then be
5 calculated for each hospital using the following formula:
6
7 SFOER = Maximum value of (1) SFOL - PDAER or (2) 0
8
9 Where:
10 SFOER = state-funds-only payment amount for each rural
11 hospital.
12 SFOL = state-funds-only payment level, which is set at
13 4 percent of TARH.
14
15 In calculating the SFOER, PDAER includes federal matching
16 funds from paragraph (b).
17 (d) The adjusted total amount allocated to the rural
18 disproportionate share program shall then be calculated using
19 the following formula:
20
21 ATARH = (TARH - SSFOER)
22
23 Where:
24 ATARH = adjusted total amount appropriated or
25 distributed under this section.
26 SSFOER = sum of the state-funds-only payment amount
27 calculated under paragraph (c) for all rural hospitals.
28 (e) The distribution of the adjusted total amount of
29 rural disproportionate share hospital funds shall then be
30 calculated using the following formula:
31
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HB 1753, First Engrossed
1 DAERH = [(TAERH x ATARH)/STAERH]
2
3 Where:
4 DAERH = distribution amount for each rural hospital.
5 (f) Federal matching funds for the disproportionate
6 share program shall then be calculated for those hospitals
7 that qualify for disproportionate share in paragraph (e).
8 (g) State-funds-only payment amounts calculated under
9 paragraph (c) and corresponding federal matching funds are
10 then added to the results of paragraph (f) to determine the
11 total distribution amount for each rural hospital. In
12 determining the payment amount for each rural hospital under
13 this section, the agency shall first allocate all available
14 state funds by the following formula:
15
16 DAER = (TAERH x TARH)/STAERH
17
18 Where:
19 DAER = distribution amount for each rural hospital.
20 STAERH = sum of total amount earned by each rural
21 hospital.
22 TAERH = total amount earned by each rural hospital.
23 TARH = total amount appropriated or distributed under
24 this section.
25
26 Federal matching funds for the disproportionate share program
27 shall then be calculated for those hospitals that qualify for
28 disproportionate share payments under this section.
29 Section 11. Paragraph (b) of subsection (3),
30 subsections (26) and (34), and paragraph (a) of subsection
31
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HB 1753, First Engrossed
1 (37) of section 409.912, Florida Statutes, are amended to
2 read:
3 409.912 Cost-effective purchasing of health care.--The
4 agency shall purchase goods and services for Medicaid
5 recipients in the most cost-effective manner consistent with
6 the delivery of quality medical care. The agency shall
7 maximize the use of prepaid per capita and prepaid aggregate
8 fixed-sum basis services when appropriate and other
9 alternative service delivery and reimbursement methodologies,
10 including competitive bidding pursuant to s. 287.057, designed
11 to facilitate the cost-effective purchase of a case-managed
12 continuum of care. The agency shall also require providers to
13 minimize the exposure of recipients to the need for acute
14 inpatient, custodial, and other institutional care and the
15 inappropriate or unnecessary use of high-cost services.
16 (3) The agency may contract with:
17 (b) An entity that provides is providing comprehensive
18 behavioral health care services to certain Medicaid recipients
19 through a capitated, prepaid arrangement pursuant to the
20 federal waiver provided for by s. 409.905(5). Such an entity
21 must be licensed under chapter 624, chapter 636, or chapter
22 641 and must possess the clinical systems and operational
23 competence to manage risk and provide comprehensive behavioral
24 health care to Medicaid recipients. As used in this paragraph,
25 the term "comprehensive behavioral health care services" means
26 covered mental health and substance abuse treatment services
27 that are available to Medicaid recipients. The secretary of
28 the Department of Children and Family Services shall approve
29 provisions of procurements related to children in the
30 department's care or custody prior to enrolling such children
31 in a prepaid behavioral health plan. Any contract awarded
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1 under this paragraph must be competitively procured. In
2 developing the behavioral health care prepaid plan procurement
3 document, the agency shall ensure that the procurement
4 document requires the contractor to develop and implement a
5 plan to ensure compliance with s. 394.4574 related to services
6 provided to residents of licensed assisted living facilities
7 that hold a limited mental health license. The agency must
8 ensure that Medicaid recipients have available the choice of
9 at least two managed care plans for their behavioral health
10 care services. The agency may continue to reimburse for
11 substance abuse treatment services on a fee-for-service basis
12 until the agency finds that adequate funds are available for
13 capitated, prepaid arrangements or until the agency determines
14 that a capitated arrangement will not adversely affect the
15 availability of substance abuse treatment services.
16 1. By January 1, 2001, the agency shall modify the
17 contracts with the entities providing comprehensive inpatient
18 and outpatient mental health care services to Medicaid
19 recipients in Hillsborough, Highlands, Hardee, Manatee, and
20 Polk Counties, to include substance-abuse-treatment services.
21 2. By December 31, 2001, the agency shall contract
22 with entities providing comprehensive behavioral health care
23 services to Medicaid recipients through capitated, prepaid
24 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
25 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
26 and Walton Counties. The agency may contract with entities
27 providing comprehensive behavioral health care services to
28 Medicaid recipients through capitated, prepaid arrangements in
29 Alachua County. The agency may determine if Sarasota County
30 shall be included as a separate catchment area or included in
31 any other agency geographic area.
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HB 1753, First Engrossed
1 1.3. Children residing in a Department of Juvenile
2 Justice residential program approved as a Medicaid behavioral
3 health overlay services provider shall not be included in a
4 behavioral health care prepaid health plan pursuant to this
5 paragraph.
6 2.4. In converting to a prepaid system of delivery,
7 the agency shall in its procurement document require an entity
8 providing comprehensive behavioral health care services to
9 prevent the displacement of indigent care patients by
10 enrollees in the Medicaid prepaid health plan providing
11 behavioral health care services from facilities receiving
12 state funding to provide indigent behavioral health care, to
13 facilities licensed under chapter 395 which do not receive
14 state funding for indigent behavioral health care, or
15 reimburse the unsubsidized facility for the cost of behavioral
16 health care provided to the displaced indigent care patient.
17 3.5. Traditional community mental health providers
18 under contract with the Department of Children and Family
19 Services pursuant to part IV of chapter 394 and inpatient
20 mental health providers licensed pursuant to chapter 395 must
21 be offered an opportunity to accept or decline a contract to
22 participate in any provider network for prepaid behavioral
23 health services.
24 (26) The agency shall conduct perform choice
25 counseling, enrollments, and disenrollments for Medicaid
26 recipients who are eligible for MediPass or managed care
27 plans. Notwithstanding the prohibition contained in paragraph
28 (18)(f), managed care plans may perform preenrollments of
29 Medicaid recipients under the supervision of the agency or its
30 agents. For the purposes of this section, "preenrollment"
31 means the provision of marketing and educational materials to
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HB 1753, First Engrossed
1 a Medicaid recipient and assistance in completing the
2 application forms, but shall not include actual enrollment
3 into a managed care plan. An application for enrollment shall
4 not be deemed complete until the agency or its agent verifies
5 that the recipient made an informed, voluntary choice. The
6 agency, in cooperation with the Department of Children and
7 Family Services, may test new marketing initiatives to inform
8 Medicaid recipients about their managed care options at
9 selected sites. The agency shall report to the Legislature on
10 the effectiveness of such initiatives. The agency may
11 contract with a third party to perform managed care plan and
12 MediPass choice-counseling, enrollment, and disenrollment
13 services for Medicaid recipients and is authorized to adopt
14 rules to implement such services. The agency may adjust the
15 capitation rate only to cover the costs of a third-party
16 choice-counseling, enrollment, and disenrollment contract, and
17 for agency supervision and management of the managed care plan
18 choice-counseling, enrollment, and disenrollment contract.
19 (34) The agency may provide for cost-effective
20 purchasing of home health services, hospital inpatient and
21 outpatient services, private duty nursing services,
22 independent laboratory services, durable medical equipment and
23 supplies, nursing home services, other long-term care
24 services, and prescribed drug services through competitive
25 bidding negotiation pursuant to s. 287.057. The agency may
26 request appropriate waivers from the federal Health Care
27 Financing Administration in order to competitively bid such
28 home health services. The agency may exclude providers not
29 selected through the bidding process from the Medicaid
30 provider network.
31
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HB 1753, First Engrossed
1 (37)(a) The agency shall implement a Medicaid
2 prescribed-drug spending-control program that includes the
3 following components:
4 1. Medicaid prescribed-drug coverage for brand-name
5 drugs for adult Medicaid recipients not residing in nursing
6 homes or other institutions is limited to the dispensing of
7 four brand-name drugs per month per recipient. Children and
8 institutionalized adults are exempt from this restriction.
9 Antiretroviral agents are excluded from this limitation. No
10 requirements for prior authorization or other restrictions on
11 medications used to treat mental illnesses such as
12 schizophrenia, severe depression, or bipolar disorder may be
13 imposed on Medicaid recipients. Medications that will be
14 available without restriction for persons with mental
15 illnesses include atypical antipsychotic medications,
16 conventional antipsychotic medications, selective serotonin
17 reuptake inhibitors, and other medications used for the
18 treatment of serious mental illnesses. The agency shall also
19 limit the amount of a prescribed drug dispensed to no more
20 than a 34-day supply. The agency shall continue to provide
21 unlimited generic drugs, contraceptive drugs and items, and
22 diabetic supplies. The agency may authorize exceptions to the
23 brand-name-drug restriction or to the restricted drug
24 formulary, based upon the treatment needs of the patients,
25 only when such exceptions are based on prior consultation
26 provided by the agency or an agency contractor, but the agency
27 must establish procedures to ensure that:
28 a. There will be a response to a request for prior
29 consultation by telephone or other telecommunication device
30 within 24 hours after receipt of a request for prior
31 consultation; and
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HB 1753, First Engrossed
1 b. A 72-hour supply of the drug prescribed will be
2 provided in an emergency or when the agency does not provide a
3 response within 24 hours as required by sub-subparagraph a.
4 2. Reimbursement to pharmacies for Medicaid prescribed
5 drugs shall be set at the lowest of the average wholesale
6 price less 13.25 percent, the wholesaler acquisition cost plus
7 7 percent, the federal or state pricing limit, or the
8 provider's usual and customary charge.
9 3. The agency shall develop and implement a process
10 for managing the drug therapies of Medicaid recipients who are
11 using significant numbers of prescribed drugs each month. The
12 management process may include, but is not limited to,
13 comprehensive, physician-directed medical-record reviews,
14 claims analyses, and case evaluations to determine the medical
15 necessity and appropriateness of a patient's treatment plan
16 and drug therapies. The agency may contract with a private
17 organization to provide drug-program-management services.
18 4. The agency may limit the size of its pharmacy
19 network based on need, competitive bidding, price
20 negotiations, credentialing, or similar criteria. The agency
21 shall give special consideration to rural areas in determining
22 the size and location of pharmacies included in the Medicaid
23 pharmacy network. A pharmacy credentialing process may include
24 criteria such as a pharmacy's full-service status, location,
25 size, patient educational programs, patient consultation,
26 disease-management services, and other characteristics. The
27 agency may impose a moratorium on Medicaid pharmacy enrollment
28 when it is determined that it has a sufficient number of
29 Medicaid-participating providers.
30 5. The agency shall develop and implement a program
31 that requires Medicaid practitioners who prescribe drugs to
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HB 1753, First Engrossed
1 use a counterfeit-proof prescription pad for Medicaid
2 prescriptions. The agency shall require the use of
3 standardized counterfeit-proof prescription pads by
4 Medicaid-participating prescribers or prescribers who write
5 prescriptions for Medicaid recipients. The agency may
6 implement the program in targeted geographic areas or
7 statewide.
8 6. The agency may enter into arrangements that require
9 manufacturers of generic drugs prescribed to Medicaid
10 recipients to provide rebates of at least 15.1 percent of the
11 average manufacturer price for the manufacturer's generic
12 products. These arrangements shall require that if a
13 generic-drug manufacturer pays federal rebates for
14 Medicaid-reimbursed drugs at a level below 15.1 percent, the
15 manufacturer must provide a supplemental rebate to the state
16 in an amount necessary to achieve a 15.1-percent rebate level.
17 If a generic-drug manufacturer raises its price in excess of
18 the Consumer Price Index (Urban), the excess amount shall be
19 included in the supplemental rebate to the state.
20 7. The agency may establish a restricted drug
21 formulary in accordance with 42 U.S.C. s. 1396r and, pursuant
22 to the establishment of such formulary, is authorized to
23 negotiate supplemental rebates from manufacturers at no less
24 than 10 percent of the average wholesale price on the last day
25 of each quarter. State supplemental manufacturer rebates shall
26 be invoiced concurrently with federal rebates.
27 Section 12. Paragraph (a) of subsection (1) and
28 subsection (7) of section 409.915, Florida Statutes, are
29 amended to read:
30 409.915 County contributions to Medicaid.--Although
31 the state is responsible for the full portion of the state
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HB 1753, First Engrossed
1 share of the matching funds required for the Medicaid program,
2 in order to acquire a certain portion of these funds, the
3 state shall charge the counties for certain items of care and
4 service as provided in this section.
5 (1) Each county shall participate in the following
6 items of care and service:
7 (a) Payments for inpatient hospitalization in excess
8 of 10 12 days, but not in excess of 45 days, with the
9 exception of pregnant women and children whose income is in
10 excess of the federal poverty level and who do not participate
11 in the Medicaid medically needy program.
12 (7) Counties are exempt from contributing toward the
13 cost of new exemptions on inpatient ceilings for statutory
14 teaching hospitals, specialty hospitals, and community
15 hospital education program hospitals that came into effect
16 July 1, 2000, and for special Medicaid payments that came into
17 effect on or after July 1, 2000. Notwithstanding any
18 provision of this section to the contrary, counties are exempt
19 from contributing toward the increased cost of hospital
20 inpatient services due to the elimination of ceilings on
21 Medicaid inpatient reimbursement rates paid to teaching
22 hospitals, specialty hospitals, and community health education
23 program hospitals and for special Medicaid reimbursements to
24 hospitals for which the Legislature has specifically
25 appropriated funds. This subsection is repealed on July 1,
26 2001.
27 Section 13. Section 636.0145, Florida Statutes, is
28 repealed:
29 636.0145 Certain entities contracting with
30 Medicaid.--Notwithstanding the requirements of s.
31 409.912(3)(b), an entity that is providing comprehensive
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HB 1753, First Engrossed
1 inpatient and outpatient mental health care services to
2 certain Medicaid recipients in Hillsborough, Highlands,
3 Hardee, Manatee, and Polk Counties through a capitated,
4 prepaid arrangement pursuant to the federal waiver provided
5 for in s. 409.905(5) must become licensed under chapter 636 by
6 December 31, 1998. Any entity licensed under this chapter
7 which provides services solely to Medicaid recipients under a
8 contract with Medicaid shall be exempt from ss. 636.017,
9 636.018, 636.022, 636.028, and 636.034.
10 Section 14. The Legislature determines and declares
11 that this act fulfills an important state interest.
12 Section 15. This act shall take effect July 1, 2001.
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