Senate Bill sb0792c1
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Florida Senate - 2001 CS for SB 792
By the Committee on Health, Aging and Long-Term Care; and
Senator Silver
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1 A bill to be entitled
2 An act relating to the Agency for Health Care
3 Administration; amending s. 409.904, F.S.;
4 revising eligibility requirements for certain
5 medical assistance payments; providing for the
6 agency to pay for health insurance premiums for
7 certain Medicaid-eligible persons; providing
8 for the agency to pay for specified cancer
9 treatment; amending s. 409.905, F.S.;
10 prescribing conditions upon which an adjustment
11 in a hospital's inpatient per diem rate may be
12 based; prescribing additional limitations that
13 may be placed on hospital inpatient services
14 under Medicaid; amending s. 409.906, F.S.;
15 providing for reimbursement and use-management
16 reforms with respect to community mental health
17 services; revising standards for payable
18 intermediate care services; amending s.
19 409.908, F.S.; revising standards, guidelines,
20 and limitations relating to reimbursement of
21 Medicaid providers; amending s. 409.911, F.S.;
22 updating data requirements and share rates for
23 disproportionate share distributions; amending
24 s. 409.9116, F.S.; modifying the formula for
25 disproportionate share/financial assistance
26 distribution to rural hospitals; amending s.
27 409.91195, F.S.; providing for a
28 restricted-drug formulary applicable to
29 Medicaid providers; revising membership of the
30 Medicaid Pharmaceutical and Therapeutics
31 Committee; authorizing the agency to negotiate
1
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1 rebates from drug manufacturers; amending s.
2 409.912, F.S.; authorizing the agency to
3 contract with children's provider networks for
4 certain purposes; specifying conditions under
5 which the agency may enter certain contracts
6 with exclusive provider organizations; revising
7 components of the agency's spending-control
8 program; prescribing additional services that
9 the agency may provide through competitive
10 bidding; authorizing the agency to establish,
11 and make exceptions to, a restricted-drug
12 formulary; amending s. 409.9122, F.S.;
13 providing for disproportionate assignment of
14 certain Medicaid-eligible children to
15 children's clinic networks; providing for
16 assignment of certain Medicaid recipients to
17 managed-care plans; amending s. 409.913, F.S.;
18 requiring the agency to implement a pilot
19 program to prevent Medicaid fraud and abuse
20 with respect to pharmaceuticals; amending s.
21 409.915, F.S.; exempting counties from
22 contributing toward the increased cost of
23 hospital inpatient services due to elimination
24 of Medicaid ceilings on certain types of
25 hospitals and for special Medicaid
26 reimbursement to hospitals; revising the level
27 of county participation; providing an effective
28 date.
29
30 Be It Enacted by the Legislature of the State of Florida:
31
2
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1 Section 1. Subsection (1) of section 409.904, Florida
2 Statutes, is amended, and subsections (9) and (10) are added
3 to that section, to read:
4 409.904 Optional payments for eligible persons.--The
5 agency may make payments for medical assistance and related
6 services on behalf of the following persons who are determined
7 to be eligible subject to the income, assets, and categorical
8 eligibility tests set forth in federal and state law. Payment
9 on behalf of these Medicaid eligible persons is subject to the
10 availability of moneys and any limitations established by the
11 General Appropriations Act or chapter 216.
12 (1) A person who is age 65 or older or is determined
13 to be disabled, whose income is at or below 87.5 100 percent
14 of federal poverty level, and whose assets do not exceed
15 established limitations.
16 (9) A Medicaid-eligible individual for the
17 individual's health insurance premiums, if the agency
18 determines that such payments are cost-effective.
19 (10) Eligible women with incomes below 200 percent of
20 the federal poverty level and from ages 50 to 64, for cancer
21 treatment pursuant to the federal Breast and Cervical Cancer
22 Prevention and Treatment Act of 2000, screened through the
23 National Breast and Cervical Cancer Early Detection program.
24 Section 2. Subsection (5) of section 409.905, Florida
25 Statutes, is amended to read:
26 409.905 Mandatory Medicaid services.--The agency may
27 make payments for the following services, which are required
28 of the state by Title XIX of the Social Security Act,
29 furnished by Medicaid providers to recipients who are
30 determined to be eligible on the dates on which the services
31 were provided. Any service under this section shall be
3
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1 provided only when medically necessary and in accordance with
2 state and federal law. Nothing in this section shall be
3 construed to prevent or limit the agency from adjusting fees,
4 reimbursement rates, lengths of stay, number of visits, number
5 of services, or any other adjustments necessary to comply with
6 the availability of moneys and any limitations or directions
7 provided for in the General Appropriations Act or chapter 216.
8 (5) HOSPITAL INPATIENT SERVICES.--The agency shall pay
9 for all covered services provided for the medical care and
10 treatment of a recipient who is admitted as an inpatient by a
11 licensed physician or dentist to a hospital licensed under
12 part I of chapter 395. However, the agency shall limit the
13 payment for inpatient hospital services for a Medicaid
14 recipient 21 years of age or older to 45 days or the number of
15 days necessary to comply with the General Appropriations Act.
16 (a) The agency is authorized to implement
17 reimbursement and utilization management reforms in order to
18 comply with any limitations or directions in the General
19 Appropriations Act, which may include, but are not limited to:
20 prior authorization for inpatient psychiatric days; prior
21 authorization for nonemergency hospital inpatient admissions;
22 authorization of emergency and urgent-care admissions within
23 24 hours after admission; enhanced utilization and concurrent
24 review programs for highly utilized services; reduction or
25 elimination of covered days of service; adjusting
26 reimbursement ceilings for variable costs; adjusting
27 reimbursement ceilings for fixed and property costs; and
28 implementing target rates of increase.
29 (b) A licensed hospital maintained primarily for the
30 care and treatment of patients having mental disorders or
31 mental diseases is not eligible to participate in the hospital
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1 inpatient portion of the Medicaid program except as provided
2 in federal law. However, the department shall apply for a
3 waiver, within 9 months after June 5, 1991, designed to
4 provide hospitalization services for mental health reasons to
5 children and adults in the most cost-effective and lowest cost
6 setting possible. Such waiver shall include a request for the
7 opportunity to pay for care in hospitals known under federal
8 law as "institutions for mental disease" or "IMD's." The
9 waiver proposal shall propose no additional aggregate cost to
10 the state or Federal Government, and shall be conducted in
11 Hillsborough County, Highlands County, Hardee County, Manatee
12 County, and Polk County. The waiver proposal may incorporate
13 competitive bidding for hospital services, comprehensive
14 brokering, prepaid capitated arrangements, or other mechanisms
15 deemed by the department to show promise in reducing the cost
16 of acute care and increasing the effectiveness of preventive
17 care. When developing the waiver proposal, the department
18 shall take into account price, quality, accessibility,
19 linkages of the hospital to community services and family
20 support programs, plans of the hospital to ensure the earliest
21 discharge possible, and the comprehensiveness of the mental
22 health and other health care services offered by participating
23 providers.
24 (c) Agency for Health Care Administration shall adjust
25 a hospital's current inpatient per diem rate to reflect the
26 cost of serving the Medicaid population at that institution
27 if:
28 1. The hospital experiences an increase in Medicaid
29 caseload by more than 25 percent in any year, primarily
30 resulting from the closure of a hospital in the same service
31 area occurring after July 1, 1995; or
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1 2. The hospital's Medicaid per diem rate is at least
2 25 percent below the Medicaid per patient cost for that year.
3
4 No later than November 1, 2001 2000, the agency must provide
5 estimated costs for any adjustment in a hospital inpatient per
6 diem pursuant to this paragraph to the Executive Office of the
7 Governor, the House of Representatives General Appropriations
8 Committee, and the Senate Appropriations Budget Committee.
9 Before the agency implements a change in a hospital's
10 inpatient per diem rate pursuant to this paragraph, the
11 Legislature must have specifically appropriated sufficient
12 funds in the 2001-2002 General Appropriations Act to support
13 the increase in cost as estimated by the agency. This
14 paragraph is repealed on July 1, 2001.
15 Section 3. Subsections (8) and (16) of section
16 409.906, Florida Statutes, are amended to read:
17 409.906 Optional Medicaid services.--Subject to
18 specific appropriations, the agency may make payments for
19 services which are optional to the state under Title XIX of
20 the Social Security Act and are furnished by Medicaid
21 providers to recipients who are determined to be eligible on
22 the dates on which the services were provided. Any optional
23 service that is provided shall be provided only when medically
24 necessary and in accordance with state and federal law.
25 Nothing in this section shall be construed to prevent or limit
26 the agency from adjusting fees, reimbursement rates, lengths
27 of stay, number of visits, or number of services, or making
28 any other adjustments necessary to comply with the
29 availability of moneys and any limitations or directions
30 provided for in the General Appropriations Act or chapter 216.
31 If necessary to safeguard the state's systems of providing
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1 services to elderly and disabled persons and subject to the
2 notice and review provisions of s. 216.177, the Governor may
3 direct the Agency for Health Care Administration to amend the
4 Medicaid state plan to delete the optional Medicaid service
5 known as "Intermediate Care Facilities for the Developmentally
6 Disabled." Optional services may include:
7 (8) COMMUNITY MENTAL HEALTH SERVICES.--
8 (a) The agency may pay for rehabilitative services
9 provided to a recipient by a mental health or substance abuse
10 provider licensed by the agency and under contract with the
11 agency or the Department of Children and Family Services to
12 provide such services. Those services which are psychiatric
13 in nature shall be rendered or recommended by a psychiatrist,
14 and those services which are medical in nature shall be
15 rendered or recommended by a physician or psychiatrist. The
16 agency must develop a provider enrollment process for
17 community mental health providers which bases provider
18 enrollment on an assessment of service need. The provider
19 enrollment process shall be designed to control costs, prevent
20 fraud and abuse, consider provider expertise and capacity, and
21 assess provider success in managing utilization of care and
22 measuring treatment outcomes. Providers will be selected
23 through a competitive procurement or selective contracting
24 process. In addition to other community mental health
25 providers, the agency shall consider for enrollment mental
26 health programs licensed under chapter 395 and group practices
27 licensed under chapter 458, chapter 459, chapter 490, or
28 chapter 491. The agency is also authorized to continue
29 operation of its behavioral health utilization management
30 program and may develop new services if these actions are
31 necessary to ensure savings from the implementation of the
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1 utilization management system. The agency shall coordinate the
2 implementation of this enrollment process with the Department
3 of Children and Family Services and the Department of Juvenile
4 Justice. The agency is authorized to utilize diagnostic
5 criteria in setting reimbursement rates, to preauthorize
6 certain high-cost or highly utilized services, to limit or
7 eliminate coverage for certain services, or to make any other
8 adjustments necessary to comply with any limitations or
9 directions provided for in the General Appropriations Act.
10 (b) The agency is authorized to implement
11 reimbursement and use management reforms in order to comply
12 with any limitations or directions in the General
13 Appropriations Act, which may include, but are not limited to:
14 prior authorization of treatment and service plans; prior
15 authorization of services; enhanced use review programs for
16 highly used services; and limits on services for those
17 determined to be abusing their benefit coverages.
18 (16) INTERMEDIATE CARE SERVICES.--The agency may pay
19 for 24-hour-a-day intermediate care nursing and rehabilitation
20 services rendered to a recipient in a nursing facility
21 licensed under part II of chapter 400, if the services are
22 ordered by and provided under the direction of a physician,
23 meet nursing home level of care criteria as determined by the
24 Comprehensive Assessment and Review for Long-Term Care (CARES)
25 Program of the Department of Elderly Affairs, and do not meet
26 the definition of the term "general care" as used in the
27 Medicaid budget estimating process.
28 Section 4. Paragraph (a) of subsection (1), paragraph
29 (b) of subsection (2), and subsections (4), (9), (11), (13),
30 (14), and (18) of section 409.908, Florida Statutes, are
31 amended to read:
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1 409.908 Reimbursement of Medicaid providers.--Subject
2 to specific appropriations, the agency shall reimburse
3 Medicaid providers, in accordance with state and federal law,
4 according to methodologies set forth in the rules of the
5 agency and in policy manuals and handbooks incorporated by
6 reference therein. These methodologies may include fee
7 schedules, reimbursement methods based on cost reporting,
8 negotiated fees, competitive bidding pursuant to s. 287.057,
9 and other mechanisms the agency considers efficient and
10 effective for purchasing services or goods on behalf of
11 recipients. Payment for Medicaid compensable services made on
12 behalf of Medicaid eligible persons is subject to the
13 availability of moneys and any limitations or directions
14 provided for in the General Appropriations Act or chapter 216.
15 Further, nothing in this section shall be construed to prevent
16 or limit the agency from adjusting fees, reimbursement rates,
17 lengths of stay, number of visits, or number of services, or
18 making any other adjustments necessary to comply with the
19 availability of moneys and any limitations or directions
20 provided for in the General Appropriations Act, provided the
21 adjustment is consistent with legislative intent.
22 (1) Reimbursement to hospitals licensed under part I
23 of chapter 395 must be made prospectively or on the basis of
24 negotiation.
25 (a) Reimbursement for inpatient care is limited as
26 provided for in s. 409.905(5), except for:
27 1. The raising of rate reimbursement caps, excluding
28 rural hospitals.
29 2. Recognition of the costs of graduate medical
30 education.
31
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1 3. Other methodologies recognized in the General
2 Appropriations Act.
3
4 During the years funds are transferred from the Board of
5 Regents, any reimbursement supported by such funds shall be
6 subject to certification by the Board of Regents that the
7 hospital has complied with s. 381.0403. The agency is
8 authorized to receive funds from state entities, including,
9 but not limited to, the Board of Regents, local governments,
10 and other local political subdivisions, for the purpose of
11 making special exception payments, including federal matching
12 funds, through the Medicaid inpatient reimbursement
13 methodologies. Funds received from state entities or local
14 governments for this purpose shall be separately accounted for
15 and shall not be commingled with other state or local funds in
16 any manner. Notwithstanding this section and s. 409.915,
17 counties are exempt from contributing toward the cost of the
18 special exception reimbursement for hospitals serving a
19 disproportionate share of low-income persons and providing
20 graduate medical education.
21 (2)
22 (b) Subject to any limitations or directions provided
23 for in the General Appropriations Act, the agency shall
24 establish and implement a Florida Title XIX Long-Term Care
25 Reimbursement Plan (Medicaid) for nursing home care in order
26 to provide care and services in conformance with the
27 applicable state and federal laws, rules, regulations, and
28 quality and safety standards and to ensure that individuals
29 eligible for medical assistance have reasonable geographic
30 access to such care. The agency shall not provide for any
31 increases in reimbursement rates to nursing homes associated
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1 with changes in ownership filed on or after January 1, 2002.
2 Under the plan, interim rate adjustments shall not be granted
3 to reflect increases in the cost of general or professional
4 liability insurance for nursing homes unless the following
5 criteria are met: have at least a 65 percent Medicaid
6 utilization in the most recent cost report submitted to the
7 agency, and the increase in general or professional liability
8 costs to the facility for the most recent policy period
9 affects the total Medicaid per diem by at least 5 percent.
10 This rate adjustment shall not result in the per diem
11 exceeding the class ceiling. This provision shall apply only
12 to fiscal year 2000-2001 and shall be implemented to the
13 extent existing appropriations are available. The agency shall
14 report to the Governor, the Speaker of the House of
15 Representatives, and the President of the Senate by December
16 31, 2000, on the cost of liability insurance for Florida
17 nursing homes for fiscal years 1999 and 2000 and the extent to
18 which these costs are not being compensated by the Medicaid
19 program. Medicaid-participating nursing homes shall be
20 required to report to the agency information necessary to
21 compile this report. Effective no earlier than the
22 rate-setting period beginning April 1, 1999, The agency shall
23 establish a case-mix reimbursement methodology for the rate of
24 payment for long-term care services for nursing home
25 residents. The agency shall compute a per diem rate for
26 Medicaid residents, adjusted for case mix, which is based on a
27 resident classification system that accounts for the relative
28 resource utilization by different types of residents and which
29 is based on level-of-care data and other appropriate data. The
30 case-mix methodology developed by the agency shall take into
31 account the medical, behavioral, and cognitive deficits of
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1 residents. In developing the reimbursement methodology, the
2 agency shall evaluate and modify other aspects of the
3 reimbursement plan as necessary to improve the overall
4 effectiveness of the plan with respect to the costs of patient
5 care, operating costs, and property costs. In the event
6 adequate data are not available, the agency is authorized to
7 adjust the patient's care component or the per diem rate to
8 more adequately cover the cost of services provided in the
9 patient's care component. The agency shall work with the
10 Department of Elderly Affairs, the Florida Health Care
11 Association, and the Florida Association of Homes for the
12 Aging in developing the methodology. It is the intent of the
13 Legislature that the reimbursement plan achieve the goal of
14 providing access to health care for nursing home residents who
15 require large amounts of care while encouraging diversion
16 services as an alternative to nursing home care for residents
17 who can be served within the community. The agency shall base
18 the establishment of any maximum rate of payment, whether
19 overall or component, on the available moneys as provided for
20 in the General Appropriations Act. The agency may base the
21 maximum rate of payment on the results of scientifically valid
22 analysis and conclusions derived from objective statistical
23 data pertinent to the particular maximum rate of payment.
24 (4) Subject to any limitations or directions provided
25 for in the General Appropriations Act, alternative health
26 plans, health maintenance organizations, and prepaid health
27 plans shall be reimbursed a fixed, prepaid amount negotiated,
28 or competitively bid pursuant to s. 287.057, by the agency and
29 prospectively paid to the provider monthly for each Medicaid
30 recipient enrolled. The amount may not exceed the average
31 amount the agency determines it would have paid, based on
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1 claims experience, for recipients in the same or similar
2 category of eligibility. The agency shall calculate
3 capitation rates on a regional basis and, beginning September
4 1, 1995, shall include age-band differentials in such
5 calculations. Effective July 1, 2001, the cost of exempting
6 statutory teaching hospitals, specialty hospitals, and
7 community hospital education program hospitals from
8 reimbursement ceilings and the cost of special Medicaid
9 payments shall not be included in premiums paid to health
10 maintenance organizations or prepaid health care plans.
11 (9) A provider of home health care services or of
12 medical supplies and appliances shall be reimbursed on the
13 basis of competitive bidding or for the lesser of the amount
14 billed by the provider or the agency's established maximum
15 allowable amount, except that, in the case of the rental of
16 durable medical equipment, the total rental payments may not
17 exceed the purchase price of the equipment over its expected
18 useful life or the agency's established maximum allowable
19 amount, whichever amount is less.
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 (13) Medicare premiums for persons eligible for both
26 Medicare and Medicaid coverage shall be paid at the rates
27 established by Title XVIII of the Social Security Act. For
28 Medicare services rendered to Medicaid-eligible persons,
29 Medicaid shall pay Medicare deductibles and coinsurance as
30 follows:
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1 (a) Medicaid shall make no payment toward deductibles
2 and coinsurance for any service that is not covered by
3 Medicaid.
4 (b) Medicaid's financial obligation for deductibles
5 and coinsurance payments shall be based on Medicare allowable
6 fees, not on a provider's billed charges.
7 (c) Medicaid will pay no portion of Medicare
8 deductibles and coinsurance when payment that Medicare has
9 made for the service equals or exceeds what Medicaid would
10 have paid if it had been the sole payor. The combined payment
11 of Medicare and Medicaid shall not exceed the amount Medicaid
12 would have paid had it been the sole payor. The Legislature
13 finds that there has been confusion regarding the
14 reimbursement for services rendered to dually eligible
15 Medicare beneficiaries. Accordingly, the Legislature clarifies
16 that it has always been the intent of the Legislature before
17 and after 1991 that, in reimbursing in accordance with fees
18 established by Title XVIII for premiums, deductibles, and
19 coinsurance for Medicare services rendered by physicians to
20 Medicaid eligible persons, physicians be reimbursed at the
21 lesser of the amount billed by the physician or the Medicaid
22 maximum allowable fee established by the Agency for Health
23 Care Administration, as is permitted by federal law. It has
24 never been the intent of the Legislature with regard to such
25 services rendered by physicians that Medicaid be required to
26 provide any payment for deductibles, coinsurance, or
27 copayments for Medicare cost sharing, or any expenses incurred
28 relating thereto, in excess of the payment amount provided for
29 under the State Medicaid plan for such service. This payment
30 methodology is applicable even in those situations in which
31 the payment for Medicare cost sharing for a qualified Medicare
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1 beneficiary with respect to an item or service is reduced or
2 eliminated. This expression of the Legislature is in
3 clarification of existing law and shall apply to payment for,
4 and with respect to provider agreements with respect to, items
5 or services furnished on or after the effective date of this
6 act. This paragraph applies to payment by Medicaid for items
7 and services furnished before the effective date of this act
8 if such payment is the subject of a lawsuit that is based on
9 the provisions of this section, and that is pending as of, or
10 is initiated after, the effective date of this act.
11 (d) Notwithstanding The following provisions are
12 exceptions to paragraphs (a)-(c):
13 1. Medicaid payments for Nursing Home Medicare part A
14 coinsurance shall be the lesser of the Medicare coinsurance
15 amount or the Medicaid nursing home per diem rate.
16 2. Medicaid shall pay all deductibles and coinsurance
17 for Nursing Home Medicare part B services.
18 2.3. Medicaid shall pay all deductibles and
19 coinsurance for Medicare-eligible recipients receiving
20 freestanding end stage renal dialysis center services.
21 4. Medicaid shall pay all deductibles and coinsurance
22 for hospital outpatient Medicare part B services.
23 3.5. Medicaid payments for general hospital inpatient
24 services shall be limited to the Medicare deductible per spell
25 of illness. Medicaid shall make no payment toward coinsurance
26 for Medicare general hospital inpatient services.
27 4.6. Medicaid shall pay all deductibles and
28 coinsurance for Medicare emergency transportation services
29 provided by ambulances licensed pursuant to chapter 401.
30 (14) A provider of prescribed drugs shall be
31 reimbursed on the basis of competitive bidding or for the
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1 least of the amount billed by the provider, the provider's
2 usual and customary charge, or the Medicaid maximum allowable
3 fee established by the agency, plus a dispensing fee. The
4 agency is directed to implement a variable dispensing fee for
5 payments for prescribed medicines while ensuring continued
6 access for Medicaid recipients. The variable dispensing fee
7 may be based upon, but not limited to, either or both the
8 volume of prescriptions dispensed by a specific pharmacy
9 provider and the volume of prescriptions dispensed to an
10 individual recipient. The agency is authorized to limit
11 reimbursement for prescribed medicine in order to comply with
12 any limitations or directions provided for in the General
13 Appropriations Act, which may include implementing a
14 prospective or concurrent utilization review program.
15 (18) Unless otherwise provided for in the General
16 Appropriations Act, a provider of transportation services
17 shall be reimbursed the lesser of the amount billed by the
18 provider or the Medicaid maximum allowable fee established by
19 the agency, except when the agency has entered into a direct
20 contract with the provider, or with a community transportation
21 coordinator, for the provision of an all-inclusive service, or
22 when services are provided pursuant to an agreement negotiated
23 between the agency and the provider. The agency, as provided
24 for in s. 427.0135, shall purchase transportation services
25 through the community coordinated transportation system, if
26 available, unless the agency determines a more cost-effective
27 method for Medicaid clients. Nothing in this subsection shall
28 be construed to limit or preclude the agency from contracting
29 for services using a prepaid capitation rate or from
30 establishing maximum fee schedules, individualized
31 reimbursement policies by provider type, negotiated fees,
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1 prior authorization, competitive bidding, increased use of
2 mass transit, or any other mechanism that the agency considers
3 efficient and effective for the purchase of services on behalf
4 of Medicaid clients, including implementing a transportation
5 eligibility process. The agency shall not be required to
6 contract with any community transportation coordinator or
7 transportation operator that has been determined by the
8 agency, the Department of Legal Affairs Medicaid Fraud Control
9 Unit, or any other state or federal agency to have engaged in
10 any abusive or fraudulent billing activities. The agency is
11 authorized to competitively procure transportation services or
12 make other changes necessary to secure approval of federal
13 waivers needed to permit federal financing of Medicaid
14 transportation services at the service matching rate rather
15 than the administrative matching rate.
16 Section 5. Paragraph (c) of subsection (1), paragraph
17 (b) of subsection (3), and subsection (7) of section 409.911,
18 Florida Statutes, are amended to read:
19 409.911 Disproportionate share program.--Subject to
20 specific allocations established within the General
21 Appropriations Act and any limitations established pursuant to
22 chapter 216, the agency shall distribute, pursuant to this
23 section, moneys to hospitals providing a disproportionate
24 share of Medicaid or charity care services by making quarterly
25 Medicaid payments as required. Notwithstanding the provisions
26 of s. 409.915, counties are exempt from contributing toward
27 the cost of this special reimbursement for hospitals serving a
28 disproportionate share of low-income patients.
29 (1) Definitions.--As used in this section and s.
30 409.9112:
31
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1 (c) "Base Medicaid per diem" means the hospital's
2 Medicaid per diem rate initially established by the Agency for
3 Health Care Administration on January 1, 1999 prior to the
4 beginning of each state fiscal year. The base Medicaid per
5 diem rate shall not include any additional per diem increases
6 received as a result of the disproportionate share
7 distribution.
8 (3) In computing the disproportionate share rate:
9 (b) The agency shall use 1994 the most recent calendar
10 year audited financial data available at the beginning of each
11 state fiscal year for the calculation of disproportionate
12 share payments under this section.
13 (7) For fiscal year 1991-1992 and all years other than
14 1992-1993, The following criteria shall be used in determining
15 the disproportionate share percentage:
16 (a) If the disproportionate share rate is less than 10
17 percent, the disproportionate share percentage is zero and
18 there is no additional payment.
19 (b) If the disproportionate share rate is greater than
20 or equal to 10 percent, but less than 20 percent, then the
21 disproportionate share percentage is 1.8478498 2.1544347.
22 (c) If the disproportionate share rate is greater than
23 or equal to 20 percent, but less than 30 percent, then the
24 disproportionate share percentage is 3.4145488 4.6415888766.
25 (d) If the disproportionate share rate is greater than
26 or equal to 30 percent, but less than 40 percent, then the
27 disproportionate share percentage is 6.3095734 10.0000001388.
28 (e) If the disproportionate share rate is greater than
29 or equal to 40 percent, but less than 50 percent, then the
30 disproportionate share percentage is 11.6591440 21.544347299.
31
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1 (f) If the disproportionate share rate is greater than
2 or equal to 50 percent, but less than 60 percent, then the
3 disproportionate share percentage is 73.5642254 46.41588941.
4 (g) If the disproportionate share rate is greater than
5 or equal to 60 percent but less than 72.5 percent, then the
6 disproportionate share percentage is 135.9356391 100.
7 (h) If the disproportionate share rate is greater than
8 or equal to 72.5 percent, then the disproportionate share
9 percentage is 170.
10 Section 6. Subsection (2) of section 409.9116, Florida
11 Statutes, is amended to read:
12 409.9116 Disproportionate share/financial assistance
13 program for rural hospitals.--In addition to the payments made
14 under s. 409.911, the Agency for Health Care Administration
15 shall administer a federally matched disproportionate share
16 program and a state-funded financial assistance program for
17 statutory rural hospitals. The agency shall make
18 disproportionate share payments to statutory rural hospitals
19 that qualify for such payments and financial assistance
20 payments to statutory rural hospitals that do not qualify for
21 disproportionate share payments. The disproportionate share
22 program payments shall be limited by and conform with federal
23 requirements. Funds shall be distributed quarterly in each
24 fiscal year for which an appropriation is made.
25 Notwithstanding the provisions of s. 409.915, counties are
26 exempt from contributing toward the cost of this special
27 reimbursement for hospitals serving a disproportionate share
28 of low-income patients.
29 (2) The agency shall use the following formula for
30 distribution of funds for the disproportionate share/financial
31 assistance program for rural hospitals.
19
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1 (a) The agency shall first determine a preliminary
2 payment amount for each rural hospital by allocating all
3 available state funds using the following formula:
4
5 PDAER = (TAERH x TARH)/STAERH
6
7 Where:
8 PDAER = preliminary distribution amount for each rural
9 hospital.
10 TAERH = total amount earned by each rural hospital.
11 TARH = total amount appropriated or distributed under
12 this section.
13 STAERH = sum of total amount earned by each rural
14 hospital.
15 (b) Federal matching funds for the disproportionate
16 share program shall then be calculated for those hospitals
17 that qualify for disproportionate share in paragraph (a).
18 (c) The state-funds-only payment amount shall then be
19 calculated for each hospital using the formula:
20
21 SFOER = Maximum value of (1) SFOL - PDAER or (2) 0
22
23 Where:
24 SFOER = state-funds-only payment amount for each rural
25 hospital.
26 SFOL = state-funds-only payment level, which is set at
27 4 percent of TARH.
28
29 In calculating the SFOER, PDAER includes federal matching
30 funds from paragraph (b).
31
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1 (d) The adjusted total amount allocated to the rural
2 disproportionate share program shall then be calculated using
3 the following formula:
4
5 ATARH = (TARH - SSFOER)
6
7 Where:
8 ATARH = adjusted total amount appropriated or
9 distributed under this section.
10 SSFOER = sum of the state-funds-only payment amount
11 calculated under paragraph (c) for all rural hospitals.
12 (e) The distribution of the adjusted total amount of
13 rural disproportionate share hospital funds shall then be
14 calculated using the following formula:
15
16 DAERH = [(TAERH x ATARH)/STAERH]
17
18 Where:
19 DAERH = distribution amount for each rural hospital.
20 (f) Federal matching funds for the disproportionate
21 share program shall then be calculated for those hospitals
22 that qualify for disproportionate share in paragraph (e).
23 (g) State-funds-only payment amounts calculated under
24 paragraph (c) and corresponding federal matching funds are
25 then added to the results of paragraph (f) to determine the
26 total distribution amount for each rural hospital.
27 In determining the payment amount for each rural
28 hospital under this section, the agency shall first allocate
29 all available state funds by the following formula:
30
31 DAER = (TAERH x TARH)/STAERH
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1
2 Where:
3 DAER = distribution amount for each rural hospital.
4 STAERH = sum of total amount earned by each rural
5 hospital.
6 TAERH = total amount earned by each rural hospital.
7 TARH = total amount appropriated or distributed under
8 this section.
9
10 Federal matching funds for the disproportionate share program
11 shall then be calculated for those hospitals that qualify for
12 disproportionate share payments under this section.
13 Section 7. Section 409.91195, Florida Statutes, is
14 amended to read:
15 409.91195 Medicaid Pharmaceutical and Therapeutics
16 Committee.--There is created a Medicaid Pharmaceutical and
17 Therapeutics Committee within the Agency for Health Care
18 Administration for the purpose of developing a restricted-drug
19 formulary under 42 U.S.C. s. 1396r-8. The committee shall
20 develop and implement a voluntary Medicaid preferred
21 prescribed drug designation program. The program shall provide
22 information to Medicaid providers on medically appropriate and
23 cost-efficient prescription drug therapies through the
24 development and publication of a voluntary Medicaid preferred
25 prescribed-drug list.
26 (1) The Medicaid Pharmaceutical and Therapeutics
27 Committee shall be comprised of nine members as specified by
28 42 U.S.C. s. 1396r-8. appointed as follows: one practicing
29 physician licensed under chapter 458, appointed by the Speaker
30 of the House of Representatives from a list of recommendations
31 from the Florida Medical Association; one practicing physician
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1 licensed under chapter 459, appointed by the Speaker of the
2 House of Representatives from a list of recommendations from
3 the Florida Osteopathic Medical Association; one practicing
4 physician licensed under chapter 458, appointed by the
5 President of the Senate from a list of recommendations from
6 the Florida Academy of Family Physicians; one practicing
7 podiatric physician licensed under chapter 461, appointed by
8 the President of the Senate from a list of recommendations
9 from the Florida Podiatric Medical Association; one trauma
10 surgeon licensed under chapter 458, appointed by the Speaker
11 of the House of Representatives from a list of recommendations
12 from the American College of Surgeons; one practicing dentist
13 licensed under chapter 466, appointed by the President of the
14 Senate from a list of recommendations from the Florida Dental
15 Association; one practicing pharmacist licensed under chapter
16 465, appointed by the Governor from a list of recommendations
17 from the Florida Pharmacy Association; one practicing
18 pharmacist licensed under chapter 465, appointed by the
19 Governor from a list of recommendations from the Florida
20 Society of Health System Pharmacists; and one health care
21 professional with expertise in clinical pharmacology appointed
22 by the Governor from a list of recommendations from the
23 Pharmaceutical Research and Manufacturers Association. The
24 members shall be appointed to serve for terms of 2 years from
25 the date of their appointment. Members may be appointed to
26 more than one term. The Agency for Health Care Administration
27 shall serve as staff for the committee and assist them with
28 all ministerial duties. The committee shall comply with rules
29 adopted by the agency.
30 (2) The Medicaid Pharmaceutical and Therapeutics
31 Committee shall develop a restricted-drug formulary for
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1 recommendation to the agency, and may recommend additions to
2 and deletions from the formulary, such that the formulary
3 provides for medically appropriate drug therapies for Medicaid
4 recipients which achieve cost savings in the Medicaid program.
5 The committee shall recommend for inclusion in the formulary:
6 (a) Any drug that has a significant, clinically
7 meaningful therapeutic advantage in terms of safety,
8 effectiveness, or clinical outcome of such treatment for such
9 population over other drugs included in the formulary, as
10 determined by the committee and as set forth in 42 U.S.C. s.
11 1396r-8;
12 (b) Any drug for which the agency has negotiated and
13 accepted a supplemental rebate pursuant to this section; and
14 (c) Any drug formulary presented to the committee by
15 the agency. Upon recommendation by the committee, the Agency
16 for Health Care Administration shall establish the voluntary
17 Medicaid preferred prescribed-drug list. Upon further
18 recommendation by the committee, the agency shall add to,
19 delete from, or modify the list. The committee shall also
20 review requests for additions to, deletions from, or
21 modifications of the list. The list shall be adopted by the
22 committee in consultation with medical specialists, when
23 appropriate, using the following criteria: use of the list
24 shall be voluntary by providers and the list must provide for
25 medically appropriate drug therapies for Medicaid patients
26 which achieve cost savings in the Medicaid program.
27 (3) Upon recommendation by the committee, the agency
28 may establish a restricted-drug formulary in accordance with
29 42 U.S.C. s. 1396r-8, and, pursuant to the establishment of
30 such formulary, is authorized to negotiate supplemental
31 rebates from manufacturers. The restricted-drug formulary must
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1 be applied to all drugs for which reimbursement is provided by
2 the Medicaid program. The agency is authorized to contract
3 with an outside agency or contractor to conduct negotiations
4 for supplemental rebates. Supplemental rebates must be
5 invoiced concurrently with federal rebate billing. For the
6 purposes of this section, the term "supplemental rebates" may
7 include, at the agency's discretion, cash rebates and other
8 program benefits that offset a state expenditure. Such other
9 program benefits may include, but are not limited to, disease
10 management programs, drug product donation programs, drug
11 utilization control programs, and other services or
12 administrative investments with guaranteed savings to the
13 Medicaid program.
14 (4) Reimbursement of drugs not included on the
15 formulary shall be subject to prior authorization by the
16 agency.
17 (5)(3) The Agency for Health Care Administration shall
18 publish and disseminate the restricted-drug formulary
19 voluntary Medicaid preferred prescribed drug list to all
20 Medicaid providers in the state.
21 Section 8. Paragraph (g) is added to subsection (3) of
22 section 409.912, Florida Statutes, and subsections (6), (34),
23 and (37) of that section are amended, to read:
24 409.912 Cost-effective purchasing of health care.--The
25 agency shall purchase goods and services for Medicaid
26 recipients in the most cost-effective manner consistent with
27 the delivery of quality medical care. The agency shall
28 maximize the use of prepaid per capita and prepaid aggregate
29 fixed-sum basis services when appropriate and other
30 alternative service delivery and reimbursement methodologies,
31 including competitive bidding pursuant to s. 287.057, designed
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1 to facilitate the cost-effective purchase of a case-managed
2 continuum of care. The agency shall also require providers to
3 minimize the exposure of recipients to the need for acute
4 inpatient, custodial, and other institutional care and the
5 inappropriate or unnecessary use of high-cost services.
6 (3) The agency may contract with:
7 (g) Children's provider networks that provide care
8 coordination and care management for Medicaid-eligible
9 pediatric patients, primary care, authorization of specialty
10 care, and other urgent and emergency care through organized
11 providers designed to service Medicaid eligibles under age 18.
12 The networks shall provide after-hour operations, including
13 evening and weekend hours, to promote, when appropriate, the
14 use of the children's networks rather than hospital emergency
15 departments.
16 (6) The agency may contract on a prepaid or fixed-sum
17 basis with an exclusive provider organization to provide
18 health care services to Medicaid recipients provided that the
19 contract does not cost more than a managed care plan contract
20 in the same agency region and that the exclusive provider
21 organization meets applicable managed care plan requirements
22 in this section, ss. 409.9122, 409.9123, 409.9128, and
23 627.6472, and other applicable provisions of law.
24 (34) The agency may provide for cost-effective
25 purchasing of home health services, private duty nursing
26 services, transportation, independent laboratory services,
27 durable medical equipment and supplies, and prescribed drug
28 services through competitive bidding negotiation pursuant to
29 s. 287.057. The agency may request appropriate waivers from
30 the federal Health Care Financing Administration in order to
31 competitively bid such home health services. The agency may
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1 exclude providers not selected through the bidding process
2 from the Medicaid provider network.
3 (37)(a) The agency shall implement a Medicaid
4 prescribed-drug spending-control program that includes the
5 following components:
6 1. Medicaid prescribed-drug coverage for brand-name
7 drugs for adult Medicaid recipients not residing in nursing
8 homes or other institutions is limited to the dispensing of
9 four brand-name drugs per month per recipient. Children and
10 institutionalized adults are exempt from this restriction.
11 Antiretroviral agents are excluded from this limitation,
12 except for prior authorization relative to the restricted-drug
13 formulary. No other requirements for prior authorization or
14 other restrictions on medications used to treat mental
15 illnesses such as schizophrenia, severe depression, or bipolar
16 disorder may be imposed on Medicaid recipients. Medications
17 that will be available without restriction for persons with
18 mental illnesses include atypical antipsychotic medications,
19 conventional antipsychotic medications, selective serotonin
20 reuptake inhibitors, and other medications used for the
21 treatment of serious mental illnesses. The agency shall also
22 limit the amount of a prescribed drug dispensed to no more
23 than a 34-day supply. The agency shall continue to provide
24 unlimited generic drugs, contraceptive drugs and items, and
25 diabetic supplies. The agency may authorize exceptions to the
26 brand-name-drug restriction or to the restricted-drug
27 formulary, based upon the treatment needs of the patients,
28 only when such exceptions are based on prior consultation
29 provided by the agency or an agency contractor, but the agency
30 must establish procedures to ensure that:
31
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1 a. There will be a response to a request for prior
2 consultation by telephone or other telecommunication device
3 within 24 hours after receipt of a request for prior
4 consultation; and
5 b. A 72-hour supply of the drug prescribed will be
6 provided in an emergency or when the agency does not provide a
7 response within 24 hours as required by sub-subparagraph a.
8 2. Reimbursement to pharmacies for Medicaid prescribed
9 drugs shall be set at the average wholesale price less 13.25
10 percent or based on competitive bid in those counties with
11 more than 35 Medicaid participating pharmacies.
12 3. The agency shall develop and implement a process
13 for managing the drug therapies of Medicaid recipients who are
14 using significant numbers of prescribed drugs each month. The
15 management process may include, but is not limited to,
16 comprehensive, physician-directed medical-record reviews,
17 claims analyses, and case evaluations to determine the medical
18 necessity and appropriateness of a patient's treatment plan
19 and drug therapies. The agency may contract with a private
20 organization to provide drug-program-management services.
21 4. The agency may limit the size of its pharmacy
22 network based on need, competitive bidding, price
23 negotiations, credentialing, or similar criteria. The agency
24 shall give special consideration to rural areas in determining
25 the size and location of pharmacies included in the Medicaid
26 pharmacy network. A pharmacy credentialing process may include
27 criteria such as a pharmacy's full-service status, location,
28 size, patient educational programs, patient consultation,
29 disease-management services, and other characteristics. The
30 agency may impose a moratorium on Medicaid pharmacy enrollment
31
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1 when it is determined that it has a sufficient number of
2 Medicaid-participating providers.
3 5. The agency shall develop and implement a program
4 that requires Medicaid practitioners who prescribe drugs to
5 use a counterfeit-proof prescription pad for Medicaid
6 prescriptions. The agency shall require the use of
7 standardized counterfeit-proof prescription pads by
8 Medicaid-participating prescribers or prescribers who write
9 prescriptions for Medicaid recipients. The agency may
10 implement the program in targeted geographic areas or
11 statewide.
12 6. The agency may enter into arrangements that require
13 manufacturers of generic drugs prescribed to Medicaid
14 recipients to provide rebates of at least 15.1 percent of the
15 average manufacturer price for the manufacturer's generic
16 products. These arrangements shall require that if a
17 generic-drug manufacturer pays federal rebates for
18 Medicaid-reimbursed drugs at a level below 15.1 percent, the
19 manufacturer must provide a supplemental rebate to the state
20 in an amount necessary to achieve a 15.1-percent rebate level.
21 If a generic-drug manufacturer raises its price in excess of
22 the Consumer Price Index (Urban), the excess amount shall be
23 included in the supplemental rebate to the state.
24 7. The agency may establish a restricted-drug
25 formulary in accordance with 42 U.S.C. s. 1396r, and, pursuant
26 to the establishment of such formulary, it is authorized to
27 negotiate supplemental rebates from manufacturers at no less
28 than 10 percent of the average manufacturer price as defined
29 in 42 U.S.C. s. 1936 on the last day of the quarter unless the
30 federal or supplemental rebate, or both, exceeds 25 percent
31 and the agency determines the product competitive. The agency
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1 may determine that specific generic products are competitive
2 at lower rebate percentages.
3 (b) The agency shall implement this subsection to the
4 extent that funds are appropriated to administer the Medicaid
5 prescribed-drug spending-control program. The agency may
6 contract all or any part of this program to private
7 organizations.
8 (c) The agency shall submit a report to the Governor,
9 the President of the Senate, and the Speaker of the House of
10 Representatives by January 15 of each year. The report must
11 include, but need not be limited to, the progress made in
12 implementing Medicaid cost-containment measures and their
13 effect on Medicaid prescribed-drug expenditures.
14 Section 9. Paragraphs (f) and (k) of subsection (2) of
15 section 409.9122, Florida Statutes, are amended to read:
16 409.9122 Mandatory Medicaid managed care enrollment;
17 programs and procedures.--
18 (2)
19 (f) When a Medicaid recipient does not choose a
20 managed care plan or MediPass provider, the agency shall
21 assign the Medicaid recipient to a managed care plan or
22 MediPass provider. Medicaid recipients who are subject to
23 mandatory assignment but who fail to make a choice shall be
24 assigned to managed care plans or provider service networks
25 until an equal enrollment of 50 percent in MediPass and
26 provider service networks and 50 percent in managed care plans
27 is achieved. Once equal enrollment is achieved, the
28 assignments shall be divided in order to maintain an equal
29 enrollment in MediPass and managed care plans for the
30 1998-1999 fiscal year. Thereafter, assignment of Medicaid
31 recipients who fail to make a choice shall be based
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1 proportionally on the preferences of recipients who have made
2 a choice in the previous period. Such proportions shall be
3 revised at least quarterly to reflect an update of the
4 preferences of Medicaid recipients. The agency shall also
5 disproportionately assign Medicaid-eligible children in
6 families who are required to but have failed to make a choice
7 of managed-care plan or MediPass for their child and who are
8 to be assigned to the MediPass program to children's networks
9 as described in s. 409.912(3)(g) and where available. The
10 disproportionate assignment of children to children's networks
11 shall be made until the agency has determined that the
12 children's networks have sufficient numbers to be economically
13 operated. When making assignments, the agency shall take into
14 account the following criteria:
15 1. A managed care plan has sufficient network capacity
16 to meet the need of members.
17 2. The managed care plan or MediPass has previously
18 enrolled the recipient as a member, or one of the managed care
19 plan's primary care providers or MediPass providers has
20 previously provided health care to the recipient.
21 3. The agency has knowledge that the member has
22 previously expressed a preference for a particular managed
23 care plan or MediPass provider as indicated by Medicaid
24 fee-for-service claims data, but has failed to make a choice.
25 4. The managed care plan's or MediPass primary care
26 providers are geographically accessible to the recipient's
27 residence.
28 (k)1. Notwithstanding the provisions of paragraph (f),
29 and for the 2000-2001 fiscal year only, when a Medicaid
30 recipient does not choose a managed care plan or MediPass
31 provider, the agency shall assign the Medicaid recipient to a
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1 managed care plan, except in those counties in which there are
2 fewer than two managed care plans accepting Medicaid
3 enrollees, in which case assignment shall be to a managed care
4 plan or a MediPass provider. Medicaid recipients in counties
5 with fewer than two managed care plans accepting Medicaid
6 enrollees who are subject to mandatory assignment but who fail
7 to make a choice shall be assigned to managed care plans until
8 an equal enrollment of 50 percent in MediPass and provider
9 service networks and 50 percent in managed care plans is
10 achieved. Once equal enrollment is achieved, the assignments
11 shall be divided in order to maintain an equal enrollment in
12 MediPass and managed care plans. When making assignments, the
13 agency shall take into account the following criteria:
14 1.a. A managed care plan has sufficient network
15 capacity to meet the need of members.
16 2.b. The managed care plan or MediPass has previously
17 enrolled the recipient as a member, or one of the managed care
18 plan's primary care providers or MediPass providers has
19 previously provided health care to the recipient.
20 3.c. The agency has knowledge that the member has
21 previously expressed a preference for a particular managed
22 care plan or MediPass provider as indicated by Medicaid
23 fee-for-service claims data, but has failed to make a choice.
24 4.d. The managed care plan's or MediPass primary care
25 providers are geographically accessible to the recipient's
26 residence.
27 5.e. The agency has authority to make mandatory
28 assignments based on quality of service and performance of
29 managed care plans.
30 2. This paragraph is repealed on July 1, 2001.
31
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1 Section 10. Subsection (26) is added to section
2 409.913, Florida Statutes, to read:
3 409.913 Oversight of the integrity of the Medicaid
4 program.--The agency shall operate a program to oversee the
5 activities of Florida Medicaid recipients, and providers and
6 their representatives, to ensure that fraudulent and abusive
7 behavior and neglect of recipients occur to the minimum extent
8 possible, and to recover overpayments and impose sanctions as
9 appropriate.
10 (26)(a) The Agency for Health Care Administration
11 shall develop and implement a pilot program to prevent
12 Medicaid fraud and abuse in Medicaid-participating pharmacies
13 by using a type of automated fingerprint imaging of Medicaid
14 beneficiaries eligible under this chapter.
15 (b) In adopting rules under this subsection, the
16 agency shall ensure that any automated fingerprint imaging
17 performed by the agency is used only to prevent fraud and
18 abuse of pharmacy benefits by Medicaid beneficiaries and is in
19 compliance with state and federal disclosure requirements.
20 (c) The agency shall prepare, by October 2001, a plan
21 for implementation of this program. Implementation shall begin
22 with a pilot of the program in one or more areas of the state
23 by April 1, 2002. The agency shall evaluate the pilot program
24 to ensure its cost effectiveness before expanding the program
25 statewide.
26 (d) The agency shall request any federal waivers
27 necessary to implement the program within the limits described
28 in this subsection.
29 Section 11. Paragraph (a) of subsection (1) and
30 subsection (7) of section 409.915, Florida Statutes, are
31 amended to read:
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1 409.915 County contributions to Medicaid.--Although
2 the state is responsible for the full portion of the state
3 share of the matching funds required for the Medicaid program,
4 in order to acquire a certain portion of these funds, the
5 state shall charge the counties for certain items of care and
6 service as provided in this section.
7 (1) Each county shall participate in the following
8 items of care and service:
9 (a) For both health maintenance members and
10 fee-for-service beneficiaries, payments for inpatient
11 hospitalization in excess of 11 12 days, but not in excess of
12 45 days, with the exception of pregnant women and children
13 whose income is in excess of the federal poverty level and who
14 do not participate in the Medicaid medically needy program.
15 (7) Counties are exempt from contributing toward the
16 cost of new exemptions on inpatient ceilings for statutory
17 teaching hospitals, specialty hospitals, and community
18 hospital education program hospitals that came into effect
19 July 1, 2000, and for special Medicaid payments that came into
20 effect on or after July 1, 2000. Notwithstanding any provision
21 of this section to the contrary, counties are exempt from
22 contributing toward the increased cost of hospital inpatient
23 services due to the elimination of ceilings on Medicaid
24 inpatient reimbursement rates paid to teaching hospitals,
25 specialty hospitals, and community health education program
26 hospitals and for special Medicaid reimbursements to hospitals
27 for which the Legislature has specifically appropriated funds.
28 This subsection is repealed on July 1, 2001.
29 Section 12. This act shall take effect July 1, 2001.
30
31
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 792
3
4 The Committee Substitute for SB 792 contains the
Medicaid-related substantive provisions of the Appropriations
5 Implementing Bill (SB 2002).
6 The bill reduces the income eligibility level for the elderly
and disabled to 87.5 percent of the federal poverty level,
7 makes Medicaid-eligible individuals who are insured eligible
for Medicaid for purposes of paying health insurance premiums
8 if the Agency for Health Care Administration (agency or AHCA)
determines this to be cost-effective, and makes certain women
9 eligible for cancer treatment. The agency is authorized to
require prior authorization for nonemergency hospital
10 inpatient admissions and for emergency and urgent-care
admissions within 24 hours after admission. The bill removes
11 the requirement that community mental health or substance
abuse providers be licensed by the agency in order to be
12 reimbursed for rehabilitative services. The agency is
authorized to implement reimbursement and use management
13 reforms for community mental health services. The bill limits
reimbursement for intermediate nursing home services to
14 persons who meet the nursing home level of care criteria as
determined by the Department of Elderly Affairs CARES program
15 and excludes reimbursement for services defined as general
care in the Medicaid budget estimating process.
16
The bill deletes an exemption for counties contributing toward
17 the cost of the special exception reimbursement for certain
hospitals providing graduate medical education. The agency is
18 prohibited from increasing nursing home reimbursements
associated with changes of ownership filed on or after January
19 1, 2002. The bill specifies that, effective July 1, 2001, the
cost of exempting certain hospitals from reimbursement
20 ceilings and the cost of special Medicaid payments are not to
be included in premiums paid to HMOs and prepaid health
21 clinics. The bill requires competitive bidding for home health
services, medical supplies and appliances, independent
22 laboratory services, and prescribed drugs. The agency is
authorized to competitively procure transportation services or
23 make changes to permit federal financing of transportation
services at the service matching rate rather than the
24 administrative matching rate. The agency may exclude providers
not selected through the competitive bidding process from the
25 Medicaid provider network. The bill deletes the requirement
that Medicaid pay deductibles and coinsurance for nursing home
26 and hospital outpatient Medicare part B services.
27 The bill modifies the formulas for calculating regular
hospital disproportionate share payments and rural hospital
28 disproportionate share payments. The Medicaid Pharmaceutical
and Therapeutics Committee provisions are revised to conform
29 to federal requirements and to develop a restricted-drug
formulary. The agency may authorize exceptions to the
30 restricted-drug formulary. Pursuant to the establishment of a
restricted-drug formulary, the agency is authorized to
31 negotiate supplemental rebates from manufacturers. The limit
of four brand-name prescription drugs per month is extended to
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1 adult Medicaid recipients in nursing homes or other
institutions. Reimbursements to pharmacies may be based on
2 competitive bids in those counties with more than 35 Medicaid
participating pharmacies.
3
The agency is authorized to contract with certain children's
4 provider networks. The agency is required to
disproportionately assign Medicaid-eligible children whose
5 families do not select a provider to a children's network
until the children's networks have sufficient numbers to be
6 economically operated.
7 The bill requires the agency to develop and implement a pilot
program to prevent Medicaid fraud and abuse in
8 Medicaid-participating pharmacies by using a type of automated
fingerprint imaging of Medicaid beneficiaries. The provisions
9 relating to county contributions to Medicaid are revised to
require county contributions for all Medicaid beneficiaries
10 for inpatient hospitalization in excess of 11 days, rather
than 12 days, but not in excess of 45 days. Counties are
11 exempt from contributing toward certain new exemptions on
inpatient ceilings and special Medicaid payments.
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22
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