CODING: Words stricken are deletions; words underlined are additions.
HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
CHAMBER ACTION
Senate House
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5 ORIGINAL STAMP BELOW
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11 Representative(s) Sobel and Frankel offered the following:
12
13 Amendment (with title amendment)
14 Remove everything after the enacting clause
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16 and insert:
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18 Be It Enacted by the Legislature of the State of Florida:
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20 Section 1. Section 16.59, Florida Statutes, is amended
21 to read:
22 16.59 Medicaid fraud control.--There is created in the
23 Department of Legal Affairs the Medicaid Fraud Control Unit,
24 which may investigate all violations of s. 409.920 and any
25 criminal violations discovered during the course of those
26 investigations. The Medicaid Fraud Control Unit may refer any
27 criminal violation so uncovered to the appropriate prosecuting
28 authority. Offices of the Medicaid Fraud Control Unit and the
29 offices of the Agency for Health Care Administration Medicaid
30 program integrity program shall, to the extent possible, be
31 colocated. The agency and the Department of Legal Affairs
1
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 shall conduct joint training and other joint activities
2 designed to increase communication and coordination in
3 recovering overpayments.
4 Section 2. Subsections (3), (5), and (7) of section
5 112.3187, Florida Statutes, are amended to read:
6 112.3187 Adverse action against employee for
7 disclosing information of specified nature prohibited;
8 employee remedy and relief.--
9 (3) DEFINITIONS.--As used in this act, unless
10 otherwise specified, the following words or terms shall have
11 the meanings indicated:
12 (a) "Agency" means any state, regional, county, local,
13 or municipal government entity, whether executive, judicial,
14 or legislative; any official, officer, department, division,
15 bureau, commission, authority, or political subdivision
16 therein; or any public school, community college, or state
17 university.
18 (b) "Employee" means a person who performs services
19 for, and under the control and direction of, or contracts
20 with, an agency or independent contractor for wages or other
21 remuneration.
22 (c) "Adverse personnel action" means the discharge,
23 suspension, transfer, or demotion of any employee or the
24 withholding of bonuses, the reduction in salary or benefits,
25 or any other adverse action taken against an employee within
26 the terms and conditions of employment by an agency or
27 independent contractor.
28 (d) "Independent contractor" means a person, other
29 than an agency, engaged in any business and who enters into a
30 contract or provider agreement with an agency.
31 (e) "Gross mismanagement" means a continuous pattern
2
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 of managerial abuses, wrongful or arbitrary and capricious
2 actions, or fraudulent or criminal conduct which may have a
3 substantial adverse economic impact.
4 (5) NATURE OF INFORMATION DISCLOSED.--The information
5 disclosed under this section must include:
6 (a) Any violation or suspected violation of any
7 federal, state, or local law, rule, or regulation committed by
8 an employee or agent of an agency or independent contractor
9 which creates and presents a substantial and specific danger
10 to the public's health, safety, or welfare.
11 (b) Any act or suspected act of gross mismanagement,
12 malfeasance, misfeasance, gross waste of public funds,
13 suspected or actual Medicaid fraud or abuse, or gross neglect
14 of duty committed by an employee or agent of an agency or
15 independent contractor.
16 (7) EMPLOYEES AND PERSONS PROTECTED.--This section
17 protects employees and persons who disclose information on
18 their own initiative in a written and signed complaint; who
19 are requested to participate in an investigation, hearing, or
20 other inquiry conducted by any agency or federal government
21 entity; who refuse to participate in any adverse action
22 prohibited by this section; or who initiate a complaint
23 through the whistle-blower's hotline or the hotline of the
24 Medicaid Fraud Control Unit of the Department of Legal
25 Affairs; or employees who file any written complaint to their
26 supervisory officials or employees who submit a complaint to
27 the Chief Inspector General in the Executive Office of the
28 Governor, to the employee designated as agency inspector
29 general under s. 112.3189(1), or to the Florida Commission on
30 Human Relations. The provisions of this section may not be
31 used by a person while he or she is under the care, custody,
3
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 or control of the state correctional system or, after release
2 from the care, custody, or control of the state correctional
3 system, with respect to circumstances that occurred during any
4 period of incarceration. No remedy or other protection under
5 ss. 112.3187-112.31895 applies to any person who has committed
6 or intentionally participated in committing the violation or
7 suspected violation for which protection under ss.
8 112.3187-112.31895 is being sought.
9 Section 3. Section 408.831, Florida Statutes, is
10 created to read:
11 408.831 Denial of application; suspension or
12 revocation of license, registration, or certificate.--
13 (1) In addition to any other remedies provided by law,
14 the agency may deny each application or suspend or revoke each
15 license, registration, or certificate of entities regulated or
16 licensed by it:
17 (a) If the applicant, licensee, registrant, or
18 certificateholder, or, in the case of a corporation,
19 partnership, or other business entity, if any officer,
20 director, agent, or managing employee of that business entity
21 or any affiliated person, partner, or shareholder having an
22 ownership interest equal to 5 percent or greater in that
23 business entity, has failed to pay all outstanding fines,
24 liens, or overpayments assessed by final order of the agency
25 or final order of the Centers for Medicare and Medicaid
26 Services unless a repayment plan is approved by the agency; or
27 (b) For failure to comply with any repayment plan.
28 (2) For all legal proceedings that may result from a
29 denial, suspension, or revocation under this section,
30 testimony or documentation from the financial entity charged
31 with monitoring such payment shall constitute evidence of the
4
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 failure to pay an outstanding fine, lien, or overpayment and
2 shall be sufficient grounds for the denial, suspension, or
3 revocation.
4 (3) This section provides standards of enforcement
5 applicable to all entities licensed or regulated by the Agency
6 for Health Care Administration. This section controls over any
7 conflicting provisions of chapters 39, 381, 383, 390, 391,
8 393, 394, 395, 400, 408, 468, 483, and 641 or rules adopted
9 pursuant to those chapters.
10 Section 4. For the purpose of incorporating the
11 amendments made by this act to sections 409.902, 409.907,
12 409.908, and 409.913, Florida Statutes, in references thereto,
13 subsection (4) of section 409.8132, Florida Statutes, is
14 reenacted to read:
15 409.8132 Medikids program component.--
16 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
17 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
18 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
19 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
20 apply to the administration of the Medikids program component
21 of the Florida Kidcare program, except that s. 409.9122
22 applies to Medikids as modified by the provisions of
23 subsection (7).
24 Section 5. Section 409.902, Florida Statutes, is
25 amended to read:
26 409.902 Designated single state agency; payment
27 requirements; program title; release of medical records.--The
28 Agency for Health Care Administration is designated as the
29 single state agency authorized to make payments for medical
30 assistance and related services under Title XIX of the Social
31 Security Act. These payments shall be made, subject to any
5
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 limitations or directions provided for in the General
2 Appropriations Act, only for services included in the program,
3 shall be made only on behalf of eligible individuals, and
4 shall be made only to qualified providers in accordance with
5 federal requirements for Title XIX of the Social Security Act
6 and the provisions of state law. This program of medical
7 assistance is designated the "Medicaid program." The
8 Department of Children and Family Services is responsible for
9 Medicaid eligibility determinations, including, but not
10 limited to, policy, rules, and the agreement with the Social
11 Security Administration for Medicaid eligibility
12 determinations for Supplemental Security Income recipients, as
13 well as the actual determination of eligibility. As a
14 condition of Medicaid eligibility, the Agency for Health Care
15 Administration and the Department of Children and Family
16 Services shall ensure that each recipient of Medicaid consents
17 to the release of her or his medical records to the Agency for
18 Health Care Administration and the Medicaid Fraud Control Unit
19 of the Department of Legal Affairs.
20 Section 6. Effective July 1, 2002, subsection (1) of
21 section 409.904, Florida Statutes, as amended by section 2 of
22 chapter 2001-377, Laws of Florida, is amended to read:
23 409.904 Optional payments for eligible persons.--The
24 agency may make payments for medical assistance and related
25 services on behalf of the following persons who are determined
26 to be eligible subject to the income, assets, and categorical
27 eligibility tests set forth in federal and state law. Payment
28 on behalf of these Medicaid eligible persons is subject to the
29 availability of moneys and any limitations established by the
30 General Appropriations Act or chapter 216.
31 (1) A person who is age 65 or older or is determined
6
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 to be disabled, whose income is at or below 90 88 percent of
2 federal poverty level, and whose assets do not exceed
3 established limitations.
4 Section 7. Subsection (2) of section 409.904, Florida
5 Statutes, as amended by section 2 of chapter 2001-377, Laws of
6 Florida, is amended to read:
7 409.904 Optional payments for eligible persons.--The
8 agency may make payments for medical assistance and related
9 services on behalf of the following persons who are determined
10 to be eligible subject to the income, assets, and categorical
11 eligibility tests set forth in federal and state law. Payment
12 on behalf of these Medicaid eligible persons is subject to the
13 availability of moneys and any limitations established by the
14 General Appropriations Act or chapter 216.
15 (2)(a) A pregnant woman who would otherwise qualify
16 for Medicaid under s. 409.903(5) except for her level of
17 income and whose assets fall within the limits established by
18 the Department of Children and Family Services for the
19 medically needy. A pregnant woman who applies for medically
20 needy eligibility may not be made presumptively eligible.
21 (b) A child under age 21 who would otherwise qualify
22 for Medicaid or the Florida Kidcare program except for the
23 family's level of income and whose assets fall within the
24 limits established by the Department of Children and Family
25 Services for the medically needy. A family, a pregnant woman,
26 a child under age 18, a person age 65 or over, or a blind or
27 disabled person who would be eligible under any group listed
28 in s. 409.903(1), (2), or (3), except that the income or
29 assets of such family or person exceed established
30 limitations. For a family or person in this group, medical
31 expenses are deductible from income in accordance with federal
7
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 requirements in order to make a determination of eligibility.
2 Expenses used to meet spend-down liability are not
3 reimbursable by Medicaid. The medically-needy income levels
4 in effect on July 1, 2001, are increased by $537 effective
5 July 1, 2002. A family or person in this group, which group
6 is known as the "medically needy," is eligible to receive the
7 same services as other Medicaid recipients, with the exception
8 of services in skilled nursing facilities and intermediate
9 care facilities for the developmentally disabled.
10 Section 8. Present subsections (8) and (10) of section
11 409.904, Florida Statutes, are amended, present subsections
12 (9), (10), and (11) are renumbered as subsections (10), (11),
13 and (12), respectively, and a new subsection (9) is added to
14 said section, to read:
15 409.904 Optional payments for eligible persons.--The
16 agency may make payments for medical assistance and related
17 services on behalf of the following persons who are determined
18 to be eligible subject to the income, assets, and categorical
19 eligibility tests set forth in federal and state law. Payment
20 on behalf of these Medicaid eligible persons is subject to the
21 availability of moneys and any limitations established by the
22 General Appropriations Act or chapter 216.
23 (8) A pregnant woman or a child under 1 year of age
24 who lives in a family that has an income above 150 185 percent
25 but not in excess of 200 percent of the most recently
26 published federal poverty level, but which is at or below 200
27 percent of such poverty level. Countable income shall be
28 determined in accordance with state and federal regulation.
29 For a pregnant woman, coverage is dependent upon federal
30 approval of coverage through Title XXI of the Social Security
31 Act. In determining the eligibility of such child, an assets
8
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 test is not required. A child who is eligible for Medicaid
2 under this subsection must be offered the opportunity, subject
3 to federal rules, to be made presumptively eligible.
4 (9) A pregnant woman for the duration of her pregnancy
5 and for the postpartum period as defined in federal law and
6 regulation, who has an income above 150 percent but not in
7 excess of 185 percent of the federal poverty level. Countable
8 income shall be determined in accordance with state and
9 federal regulation. A pregnant woman who applies for
10 eligibility for the Medicaid program shall be offered the
11 opportunity, subject to federal regulations, to be made
12 presumptively eligible. Coverage for a pregnant woman during
13 her pregnancy shall not be available should coverage become
14 available under Title XXI of the Social Security Act as
15 provided in subsection (8).
16 (11)(10)(a) Eligible women with incomes at or below
17 200 percent of the federal poverty level and under age 65, for
18 cancer treatment pursuant to the federal Breast and Cervical
19 Cancer Prevention and Treatment Act of 2000, screened through
20 the Mary Brogan National Breast and Cervical Cancer Early
21 Detection Program established under s. 381.93.
22 (b) A woman who has not attained 65 years of age and
23 who has been screened for breast or cervical cancer by a
24 qualified entity under the Mary Brogan Breast and Cervical
25 Cancer Early Detection Program of the Department of Health and
26 needs treatment for breast or cervical cancer and is not
27 otherwise covered under creditable coverage, as defined in s.
28 2701(c) of the Public Health Service Act. For purposes of this
29 subsection, the term "qualified entity" means a county public
30 health department or other entity that has contracted with the
31 Department of Health to provide breast and cervical cancer
9
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 screening services paid for under this act. In determining the
2 eligibility of such a woman, an assets test is not required. A
3 presumptive eligibility period begins on the date on which all
4 eligibility criteria appear to be met and ends on the date
5 determination is made with respect to the eligibility of such
6 woman for services under the state plan or, in the case of
7 such a woman who does not file an application, by the last day
8 of the month following the month in which the presumptive
9 eligibility determination is made. A woman is eligible until
10 she gains creditable coverage, until treatment is no longer
11 necessary, or until attainment of 65 years of age.
12 Section 9. Effective July 1, 2002, subsections (1),
13 (12) and (23) of section 409.906, Florida Statutes as amended
14 by Section 3 of chapter 2001-377, Laws of Florida, are amended
15 to read:
16 409.906 Optional Medicaid services.--Subject to
17 specific appropriations, the agency may make payments for
18 services which are optional to the state under Title XIX of
19 the Social Security Act and are furnished by Medicaid
20 providers to recipients who are determined to be eligible on
21 the dates on which the services were provided. Any optional
22 service that is provided shall be provided only when medically
23 necessary and in accordance with state and federal law.
24 Optional services rendered by providers in mobile units to
25 Medicaid recipients may be restricted or prohibited by the
26 agency. Nothing in this section shall be construed to prevent
27 or limit the agency from adjusting fees, reimbursement rates,
28 lengths of stay, number of visits, or number of services, or
29 making any other adjustments necessary to comply with the
30 availability of moneys and any limitations or directions
31 provided for in the General Appropriations Act or chapter 216.
10
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 If necessary to safeguard the state's systems of providing
2 services to elderly and disabled persons and subject to the
3 notice and review provisions of s. 216.177, the Governor may
4 direct the Agency for Health Care Administration to amend the
5 Medicaid state plan to delete the optional Medicaid service
6 known as "Intermediate Care Facilities for the Developmentally
7 Disabled." Optional services may include:
8 (1) ADULT DENTURE SERVICES.--The agency may pay for
9 dentures, the procedures required to seat dentures, and the
10 repair and reline of dentures, provided by or under the
11 direction of a licensed dentist, for a recipient who is age 21
12 or older. However, Medicaid will not provide reimbursement for
13 dental services provided in a mobile dental unit, except for a
14 mobile dental unit:
15 (a) Owned by, operated by, or having a contractual
16 agreement with the Department of Health and complying with
17 Medicaid's county health department clinic services program
18 specifications as a county health department clinic services
19 provider.
20 (b) Owned by, operated by, or having a contractual
21 arrangement with a federally qualified health center and
22 complying with Medicaid's federally qualified health center
23 specifications as a federally qualified health center
24 provider.
25 (c) Rendering dental services to Medicaid recipients,
26 21 years of age and older, at nursing facilities.
27 (d) Owned by, operated by, or having a contractual
28 agreement with a state-approved dental educational
29 institution.
30 (e) This subsection is repealed July 1, 2002.
31 (12) CHILDREN'S HEARING SERVICES.--The agency may pay
11
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 for hearing and related services, including hearing
2 evaluations, hearing aid devices, dispensing of the hearing
3 aid, and related repairs, if provided to a recipient under age
4 21 by a licensed hearing aid specialist, otolaryngologist,
5 otologist, audiologist, or physician.
6 (23) CHILDREN'S VISUAL SERVICES.--The agency may pay
7 for visual examinations, eyeglasses, and eyeglass repairs for
8 a recipient under age 21, if they are prescribed by a licensed
9 physician specializing in diseases of the eye or by a licensed
10 optometrist
11 Section 10. Effective July 1, 2002, subsection (2) of
12 section 409.9065, Florida Statutes, is amended to read:
13 409.9065 Pharmaceutical expense assistance.--
14 (2) ELIGIBILITY.--Eligibility for the program is
15 limited to those individuals who qualify for limited
16 assistance under the Florida Medicaid program as a result of
17 being dually eligible for both Medicare and Medicaid, but
18 whose limited assistance or Medicare coverage does not include
19 any pharmacy benefit. To the extent that funds are
20 appropriated, specifically eligible are low-income senior
21 citizens who:
22 (a) Are Florida residents age 65 and over;
23 (b) Have an income between 90 and 120 percent of the
24 federal poverty level, or an income between 90 and 150 percent
25 of the federal poverty level if the Federal Government raises
26 the Medicaid match to 150 percent of the federal poverty
27 level;
28 (c) Are eligible for both Medicare and Medicaid;
29 (d) Are not enrolled in a Medicare health maintenance
30 organization that provides a pharmacy benefit; and
31 (e) Request to be enrolled in the program.
12
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 Section 11. Subsections (7) and (9) of section
2 409.907, Florida Statutes, as amended by section 6 of chapter
3 2001-377, Laws of Florida, are amended to read:
4 409.907 Medicaid provider agreements.--The agency may
5 make payments for medical assistance and related services
6 rendered to Medicaid recipients only to an individual or
7 entity who has a provider agreement in effect with the agency,
8 who is performing services or supplying goods in accordance
9 with federal, state, and local law, and who agrees that no
10 person shall, on the grounds of handicap, race, color, or
11 national origin, or for any other reason, be subjected to
12 discrimination under any program or activity for which the
13 provider receives payment from the agency.
14 (7) The agency may require, as a condition of
15 participating in the Medicaid program and before entering into
16 the provider agreement, that the provider submit information,
17 in an initial and any required renewal applications,
18 concerning the professional, business, and personal background
19 of the provider and permit an onsite inspection of the
20 provider's service location by agency staff or other personnel
21 designated by the agency to perform this function. After
22 receipt of the fully completed application of a new provider,
23 the agency shall perform random onsite inspection of the
24 provider's service location to assist in determining the
25 applicant's ability to provide the services that the applicant
26 is proposing to provide for Medicaid reimbursement. The agency
27 is not required to perform an onsite inspection of a provider
28 or program that is licensed by the agency or the Department of
29 Health. As a continuing condition of participation in the
30 Medicaid program, a provider shall immediately notify the
31 agency of any current or pending bankruptcy filing. Before
13
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 entering into the provider agreement, or as a condition of
2 continuing participation in the Medicaid program, the agency
3 may also require that Medicaid providers reimbursed on a
4 fee-for-services basis or fee schedule basis which is not
5 cost-based, post a surety bond not to exceed $50,000 or the
6 total amount billed by the provider to the program during the
7 current or most recent calendar year, whichever is greater.
8 For new providers, the amount of the surety bond shall be
9 determined by the agency based on the provider's estimate of
10 its first year's billing. If the provider's billing during the
11 first year exceeds the bond amount, the agency may require the
12 provider to acquire an additional bond equal to the actual
13 billing level of the provider. A provider's bond shall not
14 exceed $50,000 if a physician or group of physicians licensed
15 under chapter 458, chapter 459, or chapter 460 has a 50
16 percent or greater ownership interest in the provider or if
17 the provider is an assisted living facility licensed under
18 part III of chapter 400. The bonds permitted by this section
19 are in addition to the bonds referenced in s. 400.179(4)(d).
20 If the provider is a corporation, partnership, association, or
21 other entity, the agency may require the provider to submit
22 information concerning the background of that entity and of
23 any principal of the entity, including any partner or
24 shareholder having an ownership interest in the entity equal
25 to 5 percent or greater, and any treating provider who
26 participates in or intends to participate in Medicaid through
27 the entity. The information must include:
28 (a) Proof of holding a valid license or operating
29 certificate, as applicable, if required by the state or local
30 jurisdiction in which the provider is located or if required
31 by the Federal Government.
14
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (b) Information concerning any prior violation, fine,
2 suspension, termination, or other administrative action taken
3 under the Medicaid laws, rules, or regulations of this state
4 or of any other state or the Federal Government; any prior
5 violation of the laws, rules, or regulations relating to the
6 Medicare program; any prior violation of the rules or
7 regulations of any other public or private insurer; and any
8 prior violation of the laws, rules, or regulations of any
9 regulatory body of this or any other state.
10 (c) Full and accurate disclosure of any financial or
11 ownership interest that the provider, or any principal,
12 partner, or major shareholder thereof, may hold in any other
13 Medicaid provider or health care related entity or any other
14 entity that is licensed by the state to provide health or
15 residential care and treatment to persons.
16 (d) If a group provider, identification of all members
17 of the group and attestation that all members of the group are
18 enrolled in or have applied to enroll in the Medicaid program.
19 (9) Upon receipt of a completed, signed, and dated
20 application, and completion of any necessary background
21 investigation and criminal history record check, the agency
22 must either:
23 (a) Enroll the applicant as a Medicaid provider no
24 earlier than the effective date of the approval of the
25 provider application. With respect to providers who were
26 recently granted a change of ownership and those who primarily
27 provide emergency medical services transportation or emergency
28 services and care pursuant to s. 401.45 or s. 395.1041, and
29 out-of-state providers, upon approval of the provider
30 application, the effective date of approval is considered to
31 be the date the agency receives the provider application; or
15
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (b) Deny the application if the agency finds that it
2 is in the best interest of the Medicaid program to do so. The
3 agency may consider the factors listed in subsection (10), as
4 well as any other factor that could affect the effective and
5 efficient administration of the program, including, but not
6 limited to, the applicant's demonstrated ability to provide
7 services, conduct business, and operate a financially viable
8 concern; the current availability of medical care, services,
9 or supplies to recipients, taking into account geographic
10 location and reasonable travel time; the number of providers
11 of the same type already enrolled in the same geographic area;
12 and the credentials, experience, success, and patient outcomes
13 of the provider for the services that it is making application
14 to provide in the Medicaid program. The agency shall deny the
15 application if the agency finds that a provider; any officer,
16 director, agent, managing employee, or affiliated person; or
17 any partner or shareholder having an ownership interest of 5
18 percent or more in the provider if the provider is a
19 corporation, partnership, or other business entity has failed
20 to pay all outstanding fines or overpayments assessed by final
21 order of the agency or final order of the Centers for Medicare
22 and Medicaid Services, unless the provider agrees to a
23 repayment plan that includes withholding Medicaid
24 reimbursement until the amount due is paid in full.
25 Section 12. The Legislature determines and declares
26 that this act fulfills an important state interest.
27 Section 13. Section 409.908, Florida Statutes, as
28 amended by section 7 of chapter 2001-377, Laws of Florida, is
29 amended to read:
30 409.908 Reimbursement of Medicaid providers.--Subject
31 to specific appropriations, the agency shall reimburse
16
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 Medicaid providers, in accordance with state and federal law,
2 according to methodologies set forth in the rules of the
3 agency and in policy manuals and handbooks incorporated by
4 reference therein. These methodologies may include fee
5 schedules, reimbursement methods based on cost reporting,
6 negotiated fees, competitive bidding pursuant to s. 287.057,
7 and other mechanisms the agency considers efficient and
8 effective for purchasing services or goods on behalf of
9 recipients. If a provider is reimbursed based on cost
10 reporting and fails to submit cost reports at the time
11 specified by the agency, the agency may withhold reimbursement
12 to the provider until a cost report is submitted that is
13 acceptable to the agency. Payment for Medicaid compensable
14 services made on behalf of Medicaid eligible persons is
15 subject to the availability of moneys and any limitations or
16 directions provided for in the General Appropriations Act or
17 chapter 216. Further, nothing in this section shall be
18 construed to prevent or limit the agency from adjusting fees,
19 reimbursement rates, lengths of stay, number of visits, or
20 number of services, or making any other adjustments necessary
21 to comply with the availability of moneys and any limitations
22 or directions provided for in the General Appropriations Act,
23 provided the 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.
27 (a) Reimbursement for inpatient care is limited as
28 provided for in s. 409.905(5), except for:
29 1. The raising of rate reimbursement caps, excluding
30 rural hospitals.
31 2. Recognition of the costs of graduate medical
17
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 education.
2 3. Other methodologies recognized in the General
3 Appropriations Act.
4 4. Hospital inpatient rates shall be reduced by 6
5 percent effective July 1, 2001, and restored effective April
6 1, 2002.
7
8 During the years funds are transferred from the Department of
9 Health, any reimbursement supported by such funds shall be
10 subject to certification by the Department of Health that the
11 hospital has complied with s. 381.0403. The agency is
12 authorized to receive funds from state entities, including,
13 but not limited to, the Department of Health, local
14 governments, and other local political subdivisions, for the
15 purpose of making special exception payments, including
16 federal matching funds, through the Medicaid inpatient
17 reimbursement methodologies. Funds received from state
18 entities or local governments for this purpose shall be
19 separately accounted for and shall not be commingled with
20 other state or local funds in any manner. The agency may
21 certify all local governmental funds used as state match under
22 Title XIX of the Social Security Act, to the extent that the
23 identified local health care provider that is otherwise
24 entitled to and is contracted to receive such local funds is
25 the benefactor under the state's Medicaid program as
26 determined under the General Appropriations Act and pursuant
27 to an agreement between the Agency for Health Care
28 Administration and the local governmental entity. The local
29 governmental entity shall use a certification form prescribed
30 by the agency. At a minimum, the certification form shall
31 identify the amount being certified and describe the
18
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 relationship between the certifying local governmental entity
2 and the local health care provider. The agency shall prepare
3 an annual statement of impact which documents the specific
4 activities undertaken during the previous fiscal year pursuant
5 to this paragraph, to be submitted to the Legislature no later
6 than January 1, annually.
7 (b) Reimbursement for hospital outpatient care is
8 limited to $1,500 per state fiscal year per recipient, except
9 for:
10 1. Such care provided to a Medicaid recipient under
11 age 21, in which case the only limitation is medical
12 necessity.
13 2. Renal dialysis services.
14 3. Other exceptions made by the agency.
15
16 The agency is authorized to receive funds from state entities,
17 including, but not limited to, the Department of Health, the
18 Board of Regents, local governments, and other local political
19 subdivisions, for the purpose of making payments, including
20 federal matching funds, through the Medicaid outpatient
21 reimbursement methodologies. Funds received from state
22 entities and local governments for this purpose shall be
23 separately accounted for and shall not be commingled with
24 other state or local funds in any manner.
25 (c) Hospitals that provide services to a
26 disproportionate share of low-income Medicaid recipients, or
27 that participate in the regional perinatal intensive care
28 center program under chapter 383, or that participate in the
29 statutory teaching hospital disproportionate share program may
30 receive additional reimbursement. The total amount of payment
31 for disproportionate share hospitals shall be fixed by the
19
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 General Appropriations Act. The computation of these payments
2 must be made in compliance with all federal regulations and
3 the methodologies described in ss. 409.911, 409.9112, and
4 409.9113.
5 (d) The agency is authorized to limit inflationary
6 increases for outpatient hospital services as directed by the
7 General Appropriations Act.
8 (2)(a)1. Reimbursement to nursing homes licensed under
9 part II of chapter 400 and state-owned-and-operated
10 intermediate care facilities for the developmentally disabled
11 licensed under chapter 393 must be made prospectively.
12 2. Unless otherwise limited or directed in the General
13 Appropriations Act, reimbursement to hospitals licensed under
14 part I of chapter 395 for the provision of swing-bed nursing
15 home services must be made on the basis of the average
16 statewide nursing home payment, and reimbursement to a
17 hospital licensed under part I of chapter 395 for the
18 provision of skilled nursing services must be made on the
19 basis of the average nursing home payment for those services
20 in the county in which the hospital is located. When a
21 hospital is located in a county that does not have any
22 community nursing homes, reimbursement must be determined by
23 averaging the nursing home payments, in counties that surround
24 the county in which the hospital is located. Reimbursement to
25 hospitals, including Medicaid payment of Medicare copayments,
26 for skilled nursing services shall be limited to 30 days,
27 unless a prior authorization has been obtained from the
28 agency. Medicaid reimbursement may be extended by the agency
29 beyond 30 days, and approval must be based upon verification
30 by the patient's physician that the patient requires
31 short-term rehabilitative and recuperative services only, in
20
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 which case an extension of no more than 15 days may be
2 approved. Reimbursement to a hospital licensed under part I of
3 chapter 395 for the temporary provision of skilled nursing
4 services to nursing home residents who have been displaced as
5 the result of a natural disaster or other emergency may not
6 exceed the average county nursing home payment for those
7 services in the county in which the hospital is located and is
8 limited to the period of time which the agency considers
9 necessary for continued placement of the nursing home
10 residents in the hospital.
11 (b) Subject to any limitations or directions provided
12 for in the General Appropriations Act, the agency shall
13 establish and implement a Florida Title XIX Long-Term Care
14 Reimbursement Plan (Medicaid) for nursing home care in order
15 to provide care and services in conformance with the
16 applicable state and federal laws, rules, regulations, and
17 quality and safety standards and to ensure that individuals
18 eligible for medical assistance have reasonable geographic
19 access to such care.
20 1. Changes of ownership or of licensed operator do not
21 qualify for increases in reimbursement rates associated with
22 the change of ownership or of licensed operator. The agency
23 shall amend the Title XIX Long Term Care Reimbursement Plan to
24 provide that the initial nursing home reimbursement rates, for
25 the operating, patient care, and MAR components, associated
26 with related and unrelated party changes of ownership or
27 licensed operator filed on or after September 1, 2001, are
28 equivalent to the previous owner's reimbursement rate.
29 2. The agency shall amend the long-term care
30 reimbursement plan and cost reporting system to create direct
31 care and indirect care subcomponents of the patient care
21
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 component of the per diem rate. These two subcomponents
2 together shall equal the patient care component of the per
3 diem rate. Separate cost-based ceilings shall be calculated
4 for each patient care subcomponent. The direct care
5 subcomponent of the per diem rate shall be limited by the
6 cost-based class ceiling, and the indirect care subcomponent
7 shall be limited by the lower of the cost-based class ceiling,
8 by the target rate class ceiling, or by the individual
9 provider target. The agency shall adjust the patient care
10 component effective January 1, 2002. The cost to adjust the
11 direct care subcomponent shall be net of the total funds
12 previously allocated for the case mix add-on. The agency shall
13 make the required changes to the nursing home cost reporting
14 forms to implement this requirement effective January 1, 2002.
15 3. The direct care subcomponent shall include salaries
16 and benefits of direct care staff providing nursing services
17 including registered nurses, licensed practical nurses, and
18 certified nursing assistants who deliver care directly to
19 residents in the nursing home facility. This excludes nursing
20 administration, MDS, and care plan coordinators, staff
21 development, and staffing coordinator.
22 4. All other patient care costs shall be included in
23 the indirect care cost subcomponent of the patient care per
24 diem rate. There shall be no costs directly or indirectly
25 allocated to the direct care subcomponent from a home office
26 or management company.
27 5. On July 1 of each year, the agency shall report to
28 the Legislature direct and indirect care costs, including
29 average direct and indirect care costs per resident per
30 facility and direct care and indirect care salaries and
31 benefits per category of staff member per facility.
22
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 6. Under the plan, interim rate adjustments shall not
2 be granted to reflect increases in the cost of general or
3 professional liability insurance for nursing homes unless the
4 following criteria are met: have at least a 65 percent
5 Medicaid utilization in the most recent cost report submitted
6 to the agency, and the increase in general or professional
7 liability costs to the facility for the most recent policy
8 period affects the total Medicaid per diem by at least 5
9 percent. This rate adjustment shall not result in the per diem
10 exceeding the class ceiling. This provision shall be
11 implemented to the extent existing appropriations are
12 available.
13
14 It is the intent of the Legislature that the reimbursement
15 plan achieve the goal of providing access to health care for
16 nursing home residents who require large amounts of care while
17 encouraging diversion services as an alternative to nursing
18 home care for residents who can be served within the
19 community. The agency shall base the establishment of any
20 maximum rate of payment, whether overall or component, on the
21 available moneys as provided for in the General Appropriations
22 Act. The agency may base the maximum rate of payment on the
23 results of scientifically valid analysis and conclusions
24 derived from objective statistical data pertinent to the
25 particular maximum rate of payment.
26 (3) Subject to any limitations or directions provided
27 for in the General Appropriations Act, the following Medicaid
28 services and goods may be reimbursed on a fee-for-service
29 basis. For each allowable service or goods furnished in
30 accordance with Medicaid rules, policy manuals, handbooks, and
31 state and federal law, the payment shall be the amount billed
23
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 by the provider, the provider's usual and customary charge, or
2 the maximum allowable fee established by the agency, whichever
3 amount is less, with the exception of those services or goods
4 for which the agency makes payment using a methodology based
5 on capitation rates, average costs, or negotiated fees.
6 (a) Advanced registered nurse practitioner services.
7 (b) Birth center services.
8 (c) Chiropractic services.
9 (d) Community mental health services.
10 (e) Dental services, including oral and maxillofacial
11 surgery.
12 (f) Durable medical equipment.
13 (g) Hearing services.
14 (h) Occupational therapy for Medicaid recipients under
15 age 21.
16 (i) Optometric services.
17 (j) Orthodontic services.
18 (k) Personal care for Medicaid recipients under age
19 21.
20 (l) Physical therapy for Medicaid recipients under age
21 21.
22 (m) Physician assistant services.
23 (n) Podiatric services.
24 (o) Portable X-ray services.
25 (p) Private-duty nursing for Medicaid recipients under
26 age 21.
27 (q) Registered nurse first assistant services.
28 (r) Respiratory therapy for Medicaid recipients under
29 age 21.
30 (s) Speech therapy for Medicaid recipients under age
31 21.
24
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (t) Visual services.
2 (4) Subject to any limitations or directions provided
3 for in the General Appropriations Act, alternative health
4 plans, health maintenance organizations, and prepaid health
5 plans shall be reimbursed a fixed, prepaid amount negotiated,
6 or competitively bid pursuant to s. 287.057, by the agency and
7 prospectively paid to the provider monthly for each Medicaid
8 recipient enrolled. The amount may not exceed the average
9 amount the agency determines it would have paid, based on
10 claims experience, for recipients in the same or similar
11 category of eligibility. The agency shall calculate
12 capitation rates on a regional basis and, beginning September
13 1, 1995, shall include age-band differentials in such
14 calculations. Effective July 1, 2001, the cost of exempting
15 statutory teaching hospitals, specialty hospitals, and
16 community hospital education program hospitals from
17 reimbursement ceilings and the cost of special Medicaid
18 payments shall not be included in premiums paid to health
19 maintenance organizations or prepaid health care plans. Each
20 rate semester, the agency shall calculate and publish a
21 Medicaid hospital rate schedule that does not reflect either
22 special Medicaid payments or the elimination of rate
23 reimbursement ceilings, to be used by hospitals and Medicaid
24 health maintenance organizations, in order to determine the
25 Medicaid rate referred to in ss. 409.912(16), 409.9128(5), and
26 641.513(6).
27 (5) An ambulatory surgical center shall be reimbursed
28 the lesser of the amount billed by the provider or the
29 Medicare-established allowable amount for the facility.
30 (6) A provider of early and periodic screening,
31 diagnosis, and treatment services to Medicaid recipients who
25
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 are children under age 21 shall be reimbursed using an
2 all-inclusive rate stipulated in a fee schedule established by
3 the agency. A provider of the visual, dental, and hearing
4 components of such services shall be reimbursed the lesser of
5 the amount billed by the provider or the Medicaid maximum
6 allowable fee established by the agency.
7 (7) A provider of family planning services shall be
8 reimbursed the lesser of the amount billed by the provider or
9 an all-inclusive amount per type of visit for physicians and
10 advanced registered nurse practitioners, as established by the
11 agency in a fee schedule.
12 (8) A provider of home-based or community-based
13 services rendered pursuant to a federally approved waiver
14 shall be reimbursed based on an established or negotiated rate
15 for each service. These rates shall be established according
16 to an analysis of the expenditure history and prospective
17 budget developed by each contract provider participating in
18 the waiver program, or under any other methodology adopted by
19 the agency and approved by the Federal Government in
20 accordance with the waiver. Effective July 1, 1996, privately
21 owned and operated community-based residential facilities
22 which meet agency requirements and which formerly received
23 Medicaid reimbursement for the optional intermediate care
24 facility for the mentally retarded service may participate in
25 the developmental services waiver as part of a
26 home-and-community-based continuum of care for Medicaid
27 recipients who receive waiver services.
28 (9) A provider of home health care services or of
29 medical supplies and appliances shall be reimbursed on the
30 basis of competitive bidding or for the lesser of the amount
31 billed by the provider or the agency's established maximum
26
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 allowable amount, except that, in the case of the rental of
2 durable medical equipment, the total rental payments may not
3 exceed the purchase price of the equipment over its expected
4 useful life or the agency's established maximum allowable
5 amount, whichever amount is less.
6 (10) A hospice shall be reimbursed through a
7 prospective system for each Medicaid hospice patient at
8 Medicaid rates using the methodology established for hospice
9 reimbursement pursuant to Title XVIII of the federal Social
10 Security Act.
11 (11) A provider of independent laboratory services
12 shall be reimbursed on the basis of competitive bidding or for
13 the least of the amount billed by the provider, the provider's
14 usual and customary charge, or the Medicaid maximum allowable
15 fee established by the agency.
16 (12)(a) A physician shall be reimbursed the lesser of
17 the amount billed by the provider or the Medicaid maximum
18 allowable fee established by the agency.
19 (b) The agency shall adopt a fee schedule, subject to
20 any limitations or directions provided for in the General
21 Appropriations Act, based on a resource-based relative value
22 scale for pricing Medicaid physician services. Under this fee
23 schedule, physicians shall be paid a dollar amount for each
24 service based on the average resources required to provide the
25 service, including, but not limited to, estimates of average
26 physician time and effort, practice expense, and the costs of
27 professional liability insurance. The fee schedule shall
28 provide increased reimbursement for preventive and primary
29 care services and lowered reimbursement for specialty services
30 by using at least two conversion factors, one for cognitive
31 services and another for procedural services. The fee
27
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 schedule shall not increase total Medicaid physician
2 expenditures unless moneys are available, and shall be phased
3 in over a 2-year period beginning on July 1, 1994. The Agency
4 for Health Care Administration shall seek the advice of a
5 16-member advisory panel in formulating and adopting the fee
6 schedule. The panel shall consist of Medicaid physicians
7 licensed under chapters 458 and 459 and shall be composed of
8 50 percent primary care physicians and 50 percent specialty
9 care physicians.
10 (c) Notwithstanding paragraph (b), reimbursement fees
11 to physicians for providing total obstetrical services to
12 Medicaid recipients, which include prenatal, delivery, and
13 postpartum care, shall be at least $1,500 per delivery for a
14 pregnant woman with low medical risk and at least $2,000 per
15 delivery for a pregnant woman with high medical risk. However,
16 reimbursement to physicians working in Regional Perinatal
17 Intensive Care Centers designated pursuant to chapter 383, for
18 services to certain pregnant Medicaid recipients with a high
19 medical risk, may be made according to obstetrical care and
20 neonatal care groupings and rates established by the agency.
21 Nurse midwives licensed under part I of chapter 464 or
22 midwives licensed under chapter 467 shall be reimbursed at no
23 less than 80 percent of the low medical risk fee. The agency
24 shall by rule determine, for the purpose of this paragraph,
25 what constitutes a high or low medical risk pregnant woman and
26 shall not pay more based solely on the fact that a caesarean
27 section was performed, rather than a vaginal delivery. The
28 agency shall by rule determine a prorated payment for
29 obstetrical services in cases where only part of the total
30 prenatal, delivery, or postpartum care was performed. The
31 Department of Health shall adopt rules for appropriate
28
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 insurance coverage for midwives licensed under chapter 467.
2 Prior to the issuance and renewal of an active license, or
3 reactivation of an inactive license for midwives licensed
4 under chapter 467, such licensees shall submit proof of
5 coverage with each application.
6 (d) For the 2001-2002 fiscal year only and if
7 necessary to meet the requirements for grants and donations
8 for the special Medicaid payments authorized in the 2001-2002
9 General Appropriations Act, the agency may make special
10 Medicaid payments to qualified Medicaid providers designated
11 by the agency, notwithstanding any provision of this
12 subsection to the contrary, and may use intergovernmental
13 transfers from state entities to serve as the state share of
14 such payments.
15 (13) Medicare premiums for persons eligible for both
16 Medicare and Medicaid coverage shall be paid at the rates
17 established by Title XVIII of the Social Security Act. For
18 Medicare services rendered to Medicaid-eligible persons,
19 Medicaid shall pay Medicare deductibles and coinsurance as
20 follows:
21 (a) Medicaid shall make no payment toward deductibles
22 and coinsurance for any service that is not covered by
23 Medicaid.
24 (b) Medicaid's financial obligation for deductibles
25 and coinsurance payments shall be based on Medicare allowable
26 fees, not on a provider's billed charges.
27 (c) Medicaid will pay no portion of Medicare
28 deductibles and coinsurance when payment that Medicare has
29 made for the service equals or exceeds what Medicaid would
30 have paid if it had been the sole payor. The combined payment
31 of Medicare and Medicaid shall not exceed the amount Medicaid
29
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 would have paid had it been the sole payor. The Legislature
2 finds that there has been confusion regarding the
3 reimbursement for services rendered to dually eligible
4 Medicare beneficiaries. Accordingly, the Legislature clarifies
5 that it has always been the intent of the Legislature before
6 and after 1991 that, in reimbursing in accordance with fees
7 established by Title XVIII for premiums, deductibles, and
8 coinsurance for Medicare services rendered by physicians to
9 Medicaid eligible persons, physicians be reimbursed at the
10 lesser of the amount billed by the physician or the Medicaid
11 maximum allowable fee established by the Agency for Health
12 Care Administration, as is permitted by federal law. It has
13 never been the intent of the Legislature with regard to such
14 services rendered by physicians that Medicaid be required to
15 provide any payment for deductibles, coinsurance, or
16 copayments for Medicare cost sharing, or any expenses incurred
17 relating thereto, in excess of the payment amount provided for
18 under the State Medicaid plan for such service. This payment
19 methodology is applicable even in those situations in which
20 the payment for Medicare cost sharing for a qualified Medicare
21 beneficiary with respect to an item or service is reduced or
22 eliminated. This expression of the Legislature is in
23 clarification of existing law and shall apply to payment for,
24 and with respect to provider agreements with respect to, items
25 or services furnished on or after the effective date of this
26 act. This paragraph applies to payment by Medicaid for items
27 and services furnished before the effective date of this act
28 if such payment is the subject of a lawsuit that is based on
29 the provisions of this section, and that is pending as of, or
30 is initiated after, the effective date of this act.
31 (d) Notwithstanding paragraphs (a)-(c):
30
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 1. Medicaid payments for Nursing Home Medicare part A
2 coinsurance shall be the lesser of the Medicare coinsurance
3 amount or the Medicaid nursing home per diem rate.
4 2. Medicaid shall pay all deductibles and coinsurance
5 for Medicare-eligible recipients receiving freestanding end
6 stage renal dialysis center services.
7 3. Medicaid payments for general hospital inpatient
8 services shall be limited to the Medicare deductible per spell
9 of illness. Medicaid shall make no payment toward coinsurance
10 for Medicare general hospital inpatient services.
11 4. Medicaid shall pay all deductibles and coinsurance
12 for Medicare emergency transportation services provided by
13 ambulances licensed pursuant to chapter 401.
14 (14) A provider of prescribed drugs shall be
15 reimbursed the least of the amount billed by the provider, the
16 provider's usual and customary charge, or the Medicaid maximum
17 allowable fee established by the agency, plus a dispensing
18 fee. The agency is directed to implement a variable dispensing
19 fee for payments for prescribed medicines while ensuring
20 continued access for Medicaid recipients. The variable
21 dispensing fee may be based upon, but not limited to, either
22 or both the volume of prescriptions dispensed by a specific
23 pharmacy provider, the volume of prescriptions dispensed to an
24 individual recipient, and dispensing of preferred-drug-list
25 products. The agency shall increase the pharmacy dispensing
26 fee authorized by statute and in the annual General
27 Appropriations Act by $0.50 for the dispensing of a Medicaid
28 preferred-drug-list product and reduce the pharmacy dispensing
29 fee by $0.50 for the dispensing of a Medicaid product that is
30 not included on the preferred-drug list. The agency is
31 authorized to limit reimbursement for prescribed medicine in
31
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 order to comply with any limitations or directions provided
2 for in the General Appropriations Act, which may include
3 implementing a prospective or concurrent utilization review
4 program.
5 (15) A provider of primary care case management
6 services rendered pursuant to a federally approved waiver
7 shall be reimbursed by payment of a fixed, prepaid monthly sum
8 for each Medicaid recipient enrolled with the provider.
9 (16) A provider of rural health clinic services and
10 federally qualified health center services shall be reimbursed
11 a rate per visit based on total reasonable costs of the
12 clinic, as determined by the agency in accordance with federal
13 regulations.
14 (17) A provider of targeted case management services
15 shall be reimbursed pursuant to an established fee, except
16 where the Federal Government requires a public provider be
17 reimbursed on the basis of average actual costs.
18 (18) Unless otherwise provided for in the General
19 Appropriations Act, a provider of transportation services
20 shall be reimbursed the lesser of the amount billed by the
21 provider or the Medicaid maximum allowable fee established by
22 the agency, except when the agency has entered into a direct
23 contract with the provider, or with a community transportation
24 coordinator, for the provision of an all-inclusive service, or
25 when services are provided pursuant to an agreement negotiated
26 between the agency and the provider. The agency, as provided
27 for in s. 427.0135, shall purchase transportation services
28 through the community coordinated transportation system, if
29 available, unless the agency determines a more cost-effective
30 method for Medicaid clients. Nothing in this subsection shall
31 be construed to limit or preclude the agency from contracting
32
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 for services using a prepaid capitation rate or from
2 establishing maximum fee schedules, individualized
3 reimbursement policies by provider type, negotiated fees,
4 prior authorization, competitive bidding, increased use of
5 mass transit, or any other mechanism that the agency considers
6 efficient and effective for the purchase of services on behalf
7 of Medicaid clients, including implementing a transportation
8 eligibility process. The agency shall not be required to
9 contract with any community transportation coordinator or
10 transportation operator that has been determined by the
11 agency, the Department of Legal Affairs Medicaid Fraud Control
12 Unit, or any other state or federal agency to have engaged in
13 any abusive or fraudulent billing activities. The agency is
14 authorized to competitively procure transportation services or
15 make other changes necessary to secure approval of federal
16 waivers needed to permit federal financing of Medicaid
17 transportation services at the service matching rate rather
18 than the administrative matching rate.
19 (19) County health department services may be
20 reimbursed a rate per visit based on total reasonable costs of
21 the clinic, as determined by the agency in accordance with
22 federal regulations under the authority of 42 C.F.R. s.
23 431.615.
24 (20) A renal dialysis facility that provides dialysis
25 services under s. 409.906(9) must be reimbursed the lesser of
26 the amount billed by the provider, the provider's usual and
27 customary charge, or the maximum allowable fee established by
28 the agency, whichever amount is less.
29 (21) The agency shall reimburse school districts which
30 certify the state match pursuant to ss. 236.0812 and 409.9071
31 for the federal portion of the school district's allowable
33
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 costs to deliver the services, based on the reimbursement
2 schedule. The school district shall determine the costs for
3 delivering services as authorized in ss. 236.0812 and 409.9071
4 for which the state match will be certified. Reimbursement of
5 school-based providers is contingent on such providers being
6 enrolled as Medicaid providers and meeting the qualifications
7 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
8 the federal Health Care Financing Administration. Speech
9 therapy providers who are certified through the Department of
10 Education pursuant to rule 6A-4.0176, Florida Administrative
11 Code, are eligible for reimbursement for services that are
12 provided on school premises. Any employee of the school
13 district who has been fingerprinted and has received a
14 criminal background check in accordance with Department of
15 Education rules and guidelines shall be exempt from any agency
16 requirements relating to criminal background checks.
17 (22) The agency shall request and implement Medicaid
18 waivers from the federal Health Care Financing Administration
19 to advance and treat a portion of the Medicaid nursing home
20 per diem as capital for creating and operating a
21 risk-retention group for self-insurance purposes, consistent
22 with federal and state laws and rules.
23 Section 14. Paragraph (b) of subsection (7) of section
24 409.910, Florida Statutes, is amended to read:
25 409.910 Responsibility for payments on behalf of
26 Medicaid-eligible persons when other parties are liable.--
27 (7) The agency shall recover the full amount of all
28 medical assistance provided by Medicaid on behalf of the
29 recipient to the full extent of third-party benefits.
30 (b) Upon receipt of any recovery or other collection
31 pursuant to this section, s. 409.913, or s. 409.920, the
34
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 agency shall distribute the amount collected as follows:
2 1. To itself and to any county that has responsibility
3 for certain items of care and service as mandated in s.
4 409.915, amounts an amount equal to a pro rata distribution of
5 the county's contribution and the state's state respective
6 Medicaid expenditures for the recipient plus any incentive
7 payment made in accordance with paragraph (14)(a). However, if
8 a county has been billed for its participation but has not
9 paid the amount due, the agency shall offset that amount and
10 notify the county of the amount of the offset. If the county
11 has divided its financial responsibility between the county
12 and a special taxing district or authority as contemplated in
13 s. 409.915(6), the county must proportionately divide any
14 refund or offset in accordance with the proration that it has
15 established.
16 2. To the Federal Government, the federal share of the
17 state Medicaid expenditures minus any incentive payment made
18 in accordance with paragraph (14)(a) and federal law, and
19 minus any other amount permitted by federal law to be
20 deducted.
21 3. To the recipient, after deducting any known amounts
22 owed to the agency for any related medical assistance or to
23 health care providers, any remaining amount. This amount shall
24 be treated as income or resources in determining eligibility
25 for Medicaid.
26
27 The provisions of this subsection do not apply to any proceeds
28 received by the state, or any agency thereof, pursuant to a
29 final order, judgment, or settlement agreement, in any matter
30 in which the state asserts claims brought on its own behalf,
31 and not as a subrogee of a recipient, or under other theories
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 of liability. The provisions of this subsection do not apply
2 to any proceeds received by the state, or an agency thereof,
3 pursuant to a final order, judgment, or settlement agreement,
4 in any matter in which the state asserted both claims as a
5 subrogee and additional claims, except as to those sums
6 specifically identified in the final order, judgment, or
7 settlement agreement as reimbursements to the recipient as
8 expenditures for the named recipient on the subrogation claim.
9 Section 15. Subsection (7) of section 409.9116,
10 Florida Statutes, is amended to read:
11 409.9116 Disproportionate share/financial assistance
12 program for rural hospitals.--In addition to the payments made
13 under s. 409.911, the Agency for Health Care Administration
14 shall administer a federally matched disproportionate share
15 program and a state-funded financial assistance program for
16 statutory rural hospitals. The agency shall make
17 disproportionate share payments to statutory rural hospitals
18 that qualify for such payments and financial assistance
19 payments to statutory rural hospitals that do not qualify for
20 disproportionate share payments. The disproportionate share
21 program payments shall be limited by and conform with federal
22 requirements. Funds shall be distributed quarterly in each
23 fiscal year for which an appropriation is made.
24 Notwithstanding the provisions of s. 409.915, counties are
25 exempt from contributing toward the cost of this special
26 reimbursement for hospitals serving a disproportionate share
27 of low-income patients.
28 (7) This section applies only to hospitals that were
29 defined as statutory rural hospitals, or their
30 successor-in-interest hospital, prior to July 1, 1999 1998.
31 Any additional hospital that is defined as a statutory rural
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Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 hospital, or its successor-in-interest hospital, on or after
2 July 1, 1999 1998, is not eligible for programs under this
3 section unless additional funds are appropriated each fiscal
4 year specifically to the rural hospital disproportionate share
5 and financial assistance programs in an amount necessary to
6 prevent any hospital, or its successor-in-interest hospital,
7 eligible for the programs prior to July 1, 1999 1998, from
8 incurring a reduction in payments because of the eligibility
9 of an additional hospital to participate in the programs. A
10 hospital, or its successor-in-interest hospital, which
11 received funds pursuant to this section before July 1, 1999
12 1998, and which qualifies under s. 395.602(2)(e), shall be
13 included in the programs under this section and is not
14 required to seek additional appropriations under this
15 subsection.
16 Section 16. Paragraph (b) of subsection (3) and
17 paragraph (b) of subsection (13) of section 409.912, Florida
18 Statutes, are amended to read:
19 409.912 Cost-effective purchasing of health care.--The
20 agency shall purchase goods and services for Medicaid
21 recipients in the most cost-effective manner consistent with
22 the delivery of quality medical care. The agency shall
23 maximize the use of prepaid per capita and prepaid aggregate
24 fixed-sum basis services when appropriate and other
25 alternative service delivery and reimbursement methodologies,
26 including competitive bidding pursuant to s. 287.057, designed
27 to facilitate the cost-effective purchase of a case-managed
28 continuum of care. The agency shall also require providers to
29 minimize the exposure of recipients to the need for acute
30 inpatient, custodial, and other institutional care and the
31 inappropriate or unnecessary use of high-cost services. The
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 agency may establish prior authorization requirements for
2 certain populations of Medicaid beneficiaries, certain drug
3 classes, or particular drugs to prevent fraud, abuse, overuse,
4 and possible dangerous drug interactions. The Pharmaceutical
5 and Therapeutics Committee shall make recommendations to the
6 agency on drugs for which prior authorization is required. The
7 agency shall inform the Pharmaceutical and Therapeutics
8 Committee of its decisions regarding drugs subject to prior
9 authorization.
10 (3) The agency may contract with:
11 (b) An entity that is providing comprehensive
12 behavioral health care services to certain Medicaid recipients
13 through a capitated, prepaid arrangement pursuant to the
14 federal waiver provided for by s. 409.905(5). Such an entity
15 must be licensed under chapter 624, chapter 636, or chapter
16 641 and must possess the clinical systems and operational
17 competence to manage risk and provide comprehensive behavioral
18 health care to Medicaid recipients. As used in this paragraph,
19 the term "comprehensive behavioral health care services" means
20 covered mental health and substance abuse treatment services
21 that are available to Medicaid recipients. The secretary of
22 the Department of Children and Family Services shall approve
23 provisions of procurements related to children in the
24 department's care or custody prior to enrolling such children
25 in a prepaid behavioral health plan. Any contract awarded
26 under this paragraph must be competitively procured. In
27 developing the behavioral health care prepaid plan procurement
28 document, the agency shall ensure that the procurement
29 document requires the contractor to develop and implement a
30 plan to ensure compliance with s. 394.4574 related to services
31 provided to residents of licensed assisted living facilities
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 that hold a limited mental health license. The agency must
2 ensure that Medicaid recipients have available the choice of
3 at least two managed care plans for their behavioral health
4 care services. To ensure unimpaired access to behavioral
5 health care services by Medicaid recipients, all contracts
6 issued pursuant to this paragraph shall require 80 percent of
7 the capitation paid to the managed care plan, including health
8 maintenance organizations, to be expended for the provision of
9 behavioral health care services. In the event the managed care
10 plan expends less than 80 percent of the capitation paid
11 pursuant to this paragraph for the provision of behavioral
12 health care services, the difference shall be returned to the
13 agency. The agency shall provide the managed care plan with a
14 certification letter indicating the amount of capitation paid
15 during each calendar year for the provision of behavioral
16 health care services pursuant to this section. The agency may
17 reimburse for substance-abuse-treatment services on a
18 fee-for-service basis until the agency finds that adequate
19 funds are available for capitated, prepaid arrangements.
20 1. By January 1, 2001, the agency shall modify the
21 contracts with the entities providing comprehensive inpatient
22 and outpatient mental health care services to Medicaid
23 recipients in Hillsborough, Highlands, Hardee, Manatee, and
24 Polk Counties, to include substance-abuse-treatment services.
25 2. By December 31, 2001, the agency shall contract
26 with entities providing comprehensive behavioral health care
27 services to Medicaid recipients through capitated, prepaid
28 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
29 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
30 and Walton Counties. The agency may contract with entities
31 providing comprehensive behavioral health care services to
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 Medicaid recipients through capitated, prepaid arrangements in
2 Alachua County. The agency may determine if Sarasota County
3 shall be included as a separate catchment area or included in
4 any other agency geographic area.
5 3. Children residing in a Department of Juvenile
6 Justice residential program approved as a Medicaid behavioral
7 health overlay services provider shall not be included in a
8 behavioral health care prepaid health plan pursuant to this
9 paragraph.
10 4. In converting to a prepaid system of delivery, the
11 agency shall in its procurement document require an entity
12 providing comprehensive behavioral health care services to
13 prevent the displacement of indigent care patients by
14 enrollees in the Medicaid prepaid health plan providing
15 behavioral health care services from facilities receiving
16 state funding to provide indigent behavioral health care, to
17 facilities licensed under chapter 395 which do not receive
18 state funding for indigent behavioral health care, or
19 reimburse the unsubsidized facility for the cost of behavioral
20 health care provided to the displaced indigent care patient.
21 5. Traditional community mental health providers under
22 contract with the Department of Children and Family Services
23 pursuant to part IV of chapter 394 and inpatient mental health
24 providers licensed pursuant to chapter 395 must be offered an
25 opportunity to accept or decline a contract to participate in
26 any provider network for prepaid behavioral health services.
27 (13)
28 (b) The responsibility of the agency under this
29 subsection shall include the development of capabilities to
30 identify actual and optimal practice patterns; patient and
31 provider educational initiatives; methods for determining
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 patient compliance with prescribed treatments; fraud, waste,
2 and abuse prevention and detection programs; and beneficiary
3 case management programs.
4 1. The practice pattern identification program shall
5 evaluate practitioner prescribing patterns based on national
6 and regional practice guidelines, comparing practitioners to
7 their peer groups. The agency and its Drug Utilization Review
8 Board shall consult with a panel of practicing health care
9 professionals consisting of the following: the Speaker of the
10 House of Representatives and the President of the Senate shall
11 each appoint three physicians licensed under chapter 458 or
12 chapter 459; and the Governor shall appoint two pharmacists
13 licensed under chapter 465 and one dentist licensed under
14 chapter 466 who is an oral surgeon. Terms of the panel members
15 shall expire at the discretion of the appointing official. The
16 panel shall begin its work by August 1, 1999, regardless of
17 the number of appointments made by that date. The advisory
18 panel shall be responsible for evaluating treatment guidelines
19 and recommending ways to incorporate their use in the practice
20 pattern identification program. Practitioners who are
21 prescribing inappropriately or inefficiently, as determined by
22 the agency, may have their prescribing of certain drugs
23 subject to prior authorization.
24 2. The agency shall also develop educational
25 interventions designed to promote the proper use of
26 medications by providers and beneficiaries.
27 3. The agency shall implement a pharmacy fraud, waste,
28 and abuse initiative that may include a surety bond or letter
29 of credit requirement for participating pharmacies, enhanced
30 provider auditing practices, the use of additional fraud and
31 abuse software, recipient management programs for
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 beneficiaries inappropriately using their benefits, and other
2 steps that will eliminate provider and recipient fraud, waste,
3 and abuse. The initiative shall address enforcement efforts to
4 reduce the number and use of counterfeit prescriptions.
5 4. By September 30, 2002, the agency shall contract
6 with an entity in the state to implement a wireless handheld
7 clinical pharmacology drug information database for
8 high-prescribing practitioners, as determined by the agency.
9 The initiative shall be designed to enhance the agency's
10 efforts to reduce fraud, abuse, and errors in the prescription
11 drug benefit program and to otherwise further the intent of
12 this paragraph.
13 5.4. The agency may apply for any federal waivers
14 needed to implement this paragraph.
15 Section 17. Paragraph (f) of subsection (2) of section
16 409.9122, Florida Statutes, as amended by section 11 of
17 chapter 2001-377, Laws of Florida, is amended to read:
18 409.9122 Mandatory Medicaid managed care enrollment;
19 programs and procedures.--
20 (2)
21 (f) When a Medicaid recipient does not choose a
22 managed care plan or MediPass provider, the agency shall
23 assign the Medicaid recipient to a managed care plan or
24 MediPass provider. Medicaid recipients who are subject to
25 mandatory assignment but who fail to make a choice shall be
26 assigned to managed care plans or provider service networks
27 until a proportional an equal enrollment of 45 50 percent in
28 MediPass and 55 50 percent in managed care plans is achieved.
29 Once the 45/55 proportional equal enrollment is achieved, the
30 assignments shall be divided in order to maintain an equal
31 enrollment in MediPass and managed care plans. Thereafter,
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 assignment of Medicaid recipients who fail to make a choice
2 shall be based proportionally on the preferences of recipients
3 who have made a choice in the previous period. Such
4 proportions shall be revised at least quarterly to reflect an
5 update of the preferences of Medicaid recipients. The agency
6 shall also disproportionately assign Medicaid-eligible
7 children in families who are required to but have failed to
8 make a choice of managed care plan or MediPass for their child
9 and who are to be assigned to the MediPass program to
10 children's networks as described in s. 409.912(3)(g) and where
11 available. The disproportionate assignment of children to
12 children's networks shall be made until the agency has
13 determined that the children's networks have sufficient
14 numbers to be economically operated. For purposes of this
15 paragraph, when referring to assignment, the term "managed
16 care plans" includes exclusive provider organizations,
17 provider service networks, minority physician networks, and
18 pediatric emergency department diversion programs authorized
19 by this chapter or the General Appropriations Act. When making
20 assignments, the agency shall take into account the following
21 criteria:
22 1. A managed care plan has sufficient network capacity
23 to meet the need of members.
24 2. The managed care plan or MediPass has previously
25 enrolled the recipient as a member, or one of the managed care
26 plan's primary care providers or MediPass providers has
27 previously provided health care to the recipient.
28 3. The agency has knowledge that the member has
29 previously expressed a preference for a particular managed
30 care plan or MediPass provider as indicated by Medicaid
31 fee-for-service claims data, but has failed to make a choice.
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 4. The managed care plan's or MediPass primary care
2 providers are geographically accessible to the recipient's
3 residence.
4 Section 18. Section 409.913, Florida Statutes, as
5 amended by section 12 of chapter 2001-377, Laws of Florida, is
6 amended to read:
7 409.913 Oversight of the integrity of the Medicaid
8 program.--The agency shall operate a program to oversee the
9 activities of Florida Medicaid recipients, and providers and
10 their representatives, to ensure that fraudulent and abusive
11 behavior and neglect of recipients occur to the minimum extent
12 possible, and to recover overpayments and impose sanctions as
13 appropriate. Beginning January 1, 2003, and each year
14 thereafter, the agency and the Medicaid Fraud Control Unit of
15 the Department of Legal Affairs shall submit a joint report to
16 the Legislature documenting the effectiveness of the state's
17 efforts to control Medicaid fraud and abuse and to recover
18 Medicaid overpayments during the previous fiscal year. The
19 report must describe the number of cases opened and
20 investigated each year; the sources of the cases opened; the
21 disposition of the cases closed each year; the amount of
22 overpayments alleged in preliminary and final audit letters;
23 the number and amount of fines or penalties imposed; any
24 reductions in overpayment amounts negotiated in settlement
25 agreements or by other means; the amount of final agency
26 determinations of overpayments; the amount deducted from
27 federal claiming as a result of overpayments; the amount of
28 overpayments recovered each year; the amount of cost of
29 investigation recovered each year; the average length of time
30 to collect from the time the case was opened until the
31 overpayment is paid in full; the amount determined as
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 uncollectible and the portion of the uncollectible amount
2 subsequently reclaimed from the Federal Government; the number
3 of providers, by type, that are terminated from participation
4 in the Medicaid program as a result of fraud and abuse; and
5 all costs associated with discovering and prosecuting cases of
6 Medicaid overpayments and making recoveries in such cases. The
7 report must also document actions taken to prevent
8 overpayments and the number of providers prevented from
9 enrolling in or reenrolling in the Medicaid program as a
10 result of documented Medicaid fraud and abuse and must
11 recommend changes necessary to prevent or recover
12 overpayments. For the 2001-2002 fiscal year, the agency shall
13 prepare a report that contains as much of this information as
14 is available to it.
15 (1) For the purposes of this section, the term:
16 (a) "Abuse" means:
17 1. Provider practices that are inconsistent with
18 generally accepted business or medical practices and that
19 result in an unnecessary cost to the Medicaid program or in
20 reimbursement for goods or services that are not medically
21 necessary or that fail to meet professionally recognized
22 standards for health care.
23 2. Recipient practices that result in unnecessary cost
24 to the Medicaid program.
25 (b) "Complaint" means an allegation that fraud, abuse,
26 or an overpayment has occurred.
27 (c)(b) "Fraud" means an intentional deception or
28 misrepresentation made by a person with the knowledge that the
29 deception results in unauthorized benefit to herself or
30 himself or another person. The term includes any act that
31 constitutes fraud under applicable federal or state law.
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (d)(c) "Medical necessity" or "medically necessary"
2 means any goods or services necessary to palliate the effects
3 of a terminal condition, or to prevent, diagnose, correct,
4 cure, alleviate, or preclude deterioration of a condition that
5 threatens life, causes pain or suffering, or results in
6 illness or infirmity, which goods or services are provided in
7 accordance with generally accepted standards of medical
8 practice. For purposes of determining Medicaid reimbursement,
9 the agency is the final arbiter of medical necessity.
10 Determinations of medical necessity must be made by a licensed
11 physician employed by or under contract with the agency and
12 must be based upon information available at the time the goods
13 or services are provided.
14 (e)(d) "Overpayment" includes any amount that is not
15 authorized to be paid by the Medicaid program whether paid as
16 a result of inaccurate or improper cost reporting, improper
17 claiming, unacceptable practices, fraud, abuse, or mistake.
18 (f)(e) "Person" means any natural person, corporation,
19 partnership, association, clinic, group, or other entity,
20 whether or not such person is enrolled in the Medicaid program
21 or is a provider of health care.
22 (2) The agency shall conduct, or cause to be conducted
23 by contract or otherwise, reviews, investigations, analyses,
24 audits, or any combination thereof, to determine possible
25 fraud, abuse, overpayment, or recipient neglect in the
26 Medicaid program and shall report the findings of any
27 overpayments in audit reports as appropriate.
28 (3) The agency may conduct, or may contract for,
29 prepayment review of provider claims to ensure cost-effective
30 purchasing, billing, and provision of care to Medicaid
31 recipients. Such prepayment reviews may be conducted as
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 determined appropriate by the agency, without any suspicion or
2 allegation of fraud, abuse, or neglect.
3 (4) Any suspected criminal violation identified by the
4 agency must be referred to the Medicaid Fraud Control Unit of
5 the Office of the Attorney General for investigation. The
6 agency and the Attorney General shall enter into a memorandum
7 of understanding, which must include, but need not be limited
8 to, a protocol for regularly sharing information and
9 coordinating casework. The protocol must establish a
10 procedure for the referral by the agency of cases involving
11 suspected Medicaid fraud to the Medicaid Fraud Control Unit
12 for investigation, and the return to the agency of those cases
13 where investigation determines that administrative action by
14 the agency is appropriate. Offices of the Medicaid program
15 integrity program and the Medicaid Fraud Control Unit of the
16 Department of Legal Affairs shall, to the extent possible, be
17 colocated. The agency and the Department of Legal Affairs
18 shall periodically conduct joint training and other joint
19 activities designed to increase communication and coordination
20 in recovering overpayments.
21 (5) A Medicaid provider is subject to having goods and
22 services that are paid for by the Medicaid program reviewed by
23 an appropriate peer-review organization designated by the
24 agency. The written findings of the applicable peer-review
25 organization are admissible in any court or administrative
26 proceeding as evidence of medical necessity or the lack
27 thereof.
28 (6) Any notice required to be given to a provider
29 under this section is presumed to be sufficient notice if sent
30 to the address last shown on the provider enrollment file. It
31 is the responsibility of the provider to furnish and keep the
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 agency informed of the provider's current address. United
2 States Postal Service proof of mailing or certified or
3 registered mailing of such notice to the provider at the
4 address shown on the provider enrollment file constitutes
5 sufficient proof of notice. Any notice required to be given to
6 the agency by this section must be sent to the agency at an
7 address designated by rule.
8 (7) When presenting a claim for payment under the
9 Medicaid program, a provider has an affirmative duty to
10 supervise the provision of, and be responsible for, goods and
11 services claimed to have been provided, to supervise and be
12 responsible for preparation and submission of the claim, and
13 to present a claim that is true and accurate and that is for
14 goods and services that:
15 (a) Have actually been furnished to the recipient by
16 the provider prior to submitting the claim.
17 (b) Are Medicaid-covered goods or services that are
18 medically necessary.
19 (c) Are of a quality comparable to those furnished to
20 the general public by the provider's peers.
21 (d) Have not been billed in whole or in part to a
22 recipient or a recipient's responsible party, except for such
23 copayments, coinsurance, or deductibles as are authorized by
24 the agency.
25 (e) Are provided in accord with applicable provisions
26 of all Medicaid rules, regulations, handbooks, and policies
27 and in accordance with federal, state, and local law.
28 (f) Are documented by records made at the time the
29 goods or services were provided, demonstrating the medical
30 necessity for the goods or services rendered. Medicaid goods
31 or services are excessive or not medically necessary unless
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 both the medical basis and the specific need for them are
2 fully and properly documented in the recipient's medical
3 record.
4 (8) A Medicaid provider shall retain medical,
5 professional, financial, and business records pertaining to
6 services and goods furnished to a Medicaid recipient and
7 billed to Medicaid for a period of 5 years after the date of
8 furnishing such services or goods. The agency may investigate,
9 review, or analyze such records, which must be made available
10 during normal business hours. However, 24-hour notice must be
11 provided if patient treatment would be disrupted. The provider
12 is responsible for furnishing to the agency, and keeping the
13 agency informed of the location of, the provider's
14 Medicaid-related records. The authority of the agency to
15 obtain Medicaid-related records from a provider is neither
16 curtailed nor limited during a period of litigation between
17 the agency and the provider.
18 (9) Payments for the services of billing agents or
19 persons participating in the preparation of a Medicaid claim
20 shall not be based on amounts for which they bill nor based on
21 the amount a provider receives from the Medicaid program.
22 (10) The agency may require repayment for
23 inappropriate, medically unnecessary, or excessive goods or
24 services from the person furnishing them, the person under
25 whose supervision they were furnished, or the person causing
26 them to be furnished.
27 (11) The complaint and all information obtained
28 pursuant to an investigation of a Medicaid provider, or the
29 authorized representative or agent of a provider, relating to
30 an allegation of fraud, abuse, or neglect are confidential and
31 exempt from the provisions of s. 119.07(1):
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (a) Until the agency takes final agency action with
2 respect to the provider and requires repayment of any
3 overpayment, or imposes an administrative sanction;
4 (b) Until the Attorney General refers the case for
5 criminal prosecution;
6 (c) Until 10 days after the complaint is determined
7 without merit; or
8 (d) At all times if the complaint or information is
9 otherwise protected by law.
10 (12) The agency may terminate participation of a
11 Medicaid provider in the Medicaid program and may seek civil
12 remedies or impose other administrative sanctions against a
13 Medicaid provider, if the provider has been:
14 (a) Convicted of a criminal offense related to the
15 delivery of any health care goods or services, including the
16 performance of management or administrative functions relating
17 to the delivery of health care goods or services;
18 (b) Convicted of a criminal offense under federal law
19 or the law of any state relating to the practice of the
20 provider's profession; or
21 (c) Found by a court of competent jurisdiction to have
22 neglected or physically abused a patient in connection with
23 the delivery of health care goods or services.
24 (13) If the provider has been suspended or terminated
25 from participation in the Medicaid program or the Medicare
26 program by the Federal Government or any state, the agency
27 must immediately suspend or terminate, as appropriate, the
28 provider's participation in the Florida Medicaid program for a
29 period no less than that imposed by the Federal Government or
30 any other state, and may not enroll such provider in the
31 Florida Medicaid program while such foreign suspension or
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 termination remains in effect. This sanction is in addition
2 to all other remedies provided by law.
3 (14) The agency may seek any remedy provided by law,
4 including, but not limited to, the remedies provided in
5 subsections (12) and (15) and s. 812.035, if:
6 (a) The provider's license has not been renewed, or
7 has been revoked, suspended, or terminated, for cause, by the
8 licensing agency of any state;
9 (b) The provider has failed to make available or has
10 refused access to Medicaid-related records to an auditor,
11 investigator, or other authorized employee or agent of the
12 agency, the Attorney General, a state attorney, or the Federal
13 Government;
14 (c) The provider has not furnished or has failed to
15 make available such Medicaid-related records as the agency has
16 found necessary to determine whether Medicaid payments are or
17 were due and the amounts thereof;
18 (d) The provider has failed to maintain medical
19 records made at the time of service, or prior to service if
20 prior authorization is required, demonstrating the necessity
21 and appropriateness of the goods or services rendered;
22 (e) The provider is not in compliance with provisions
23 of Medicaid provider publications that have been adopted by
24 reference as rules in the Florida Administrative Code; with
25 provisions of state or federal laws, rules, or regulations;
26 with provisions of the provider agreement between the agency
27 and the provider; or with certifications found on claim forms
28 or on transmittal forms for electronically submitted claims
29 that are submitted by the provider or authorized
30 representative, as such provisions apply to the Medicaid
31 program;
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (f) The provider or person who ordered or prescribed
2 the care, services, or supplies has furnished, or ordered the
3 furnishing of, goods or services to a recipient which are
4 inappropriate, unnecessary, excessive, or harmful to the
5 recipient or are of inferior quality;
6 (g) The provider has demonstrated a pattern of failure
7 to provide goods or services that are medically necessary;
8 (h) The provider or an authorized representative of
9 the provider, or a person who ordered or prescribed the goods
10 or services, has submitted or caused to be submitted false or
11 a pattern of erroneous Medicaid claims that have resulted in
12 overpayments to a provider or that exceed those to which the
13 provider was entitled under the Medicaid program;
14 (i) The provider or an authorized representative of
15 the provider, or a person who has ordered or prescribed the
16 goods or services, has submitted or caused to be submitted a
17 Medicaid provider enrollment application, a request for prior
18 authorization for Medicaid services, a drug exception request,
19 or a Medicaid cost report that contains materially false or
20 incorrect information;
21 (j) The provider or an authorized representative of
22 the provider has collected from or billed a recipient or a
23 recipient's responsible party improperly for amounts that
24 should not have been so collected or billed by reason of the
25 provider's billing the Medicaid program for the same service;
26 (k) The provider or an authorized representative of
27 the provider has included in a cost report costs that are not
28 allowable under a Florida Title XIX reimbursement plan, after
29 the provider or authorized representative had been advised in
30 an audit exit conference or audit report that the costs were
31 not allowable;
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Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (l) The provider is charged by information or
2 indictment with fraudulent billing practices. The sanction
3 applied for this reason is limited to suspension of the
4 provider's participation in the Medicaid program for the
5 duration of the indictment unless the provider is found guilty
6 pursuant to the information or indictment;
7 (m) The provider or a person who has ordered, or
8 prescribed the goods or services is found liable for negligent
9 practice resulting in death or injury to the provider's
10 patient;
11 (n) The provider fails to demonstrate that it had
12 available during a specific audit or review period sufficient
13 quantities of goods, or sufficient time in the case of
14 services, to support the provider's billings to the Medicaid
15 program;
16 (o) The provider has failed to comply with the notice
17 and reporting requirements of s. 409.907; or
18 (p) The agency has received reliable information of
19 patient abuse or neglect or of any act prohibited by s.
20 409.920;.
21 (q) The provider has failed to comply with an
22 agreed-upon repayment schedule; or
23 (r) The provider has failed to timely file such
24 Medicaid cost reports as the agency considers necessary to set
25 or adjust payment rates.
26 (15) The agency shall may impose any of the following
27 sanctions or disincentives on a provider or a person for any
28 of the acts described in subsection (14):
29 (a) Suspension for a specific period of time of not
30 more than 1 year.
31 (b) Termination for a specific period of time of from
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 more than 1 year to 20 years.
2 (c) Imposition of a fine of up to $5,000 for each
3 violation. Each day that an ongoing violation continues, such
4 as refusing to furnish Medicaid-related records or refusing
5 access to records, is considered, for the purposes of this
6 section, to be a separate violation. Each instance of
7 improper billing of a Medicaid recipient; each instance of
8 including an unallowable cost on a hospital or nursing home
9 Medicaid cost report after the provider or authorized
10 representative has been advised in an audit exit conference or
11 previous audit report of the cost unallowability; each
12 instance of furnishing a Medicaid recipient goods or
13 professional services that are inappropriate or of inferior
14 quality as determined by competent peer judgment; each
15 instance of knowingly submitting a materially false or
16 erroneous Medicaid provider enrollment application, request
17 for prior authorization for Medicaid services, drug exception
18 request, or cost report; each instance of inappropriate
19 prescribing of drugs for a Medicaid recipient as determined by
20 competent peer judgment; and each false or erroneous Medicaid
21 claim leading to an overpayment to a provider is considered,
22 for the purposes of this section, to be a separate violation.
23 (d) Immediate suspension, if the agency has received
24 information of patient abuse or neglect or of any act
25 prohibited by s. 409.920. Upon suspension, the agency must
26 issue an immediate final order under s. 120.569(2)(n).
27 (e) A fine, not to exceed $10,000, for a violation of
28 paragraph (14)(i).
29 (f) Imposition of liens against provider assets,
30 including, but not limited to, financial assets and real
31 property, not to exceed the amount of fines or recoveries
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 sought, upon entry of an order determining that such moneys
2 are due or recoverable.
3 (g) Prepayment reviews of claims for a specified
4 period of time.
5 (h) Comprehensive followup reviews of providers every
6 6 months to ensure that they are billing Medicaid correctly.
7 (i) Corrective action plans that would remain in
8 effect for providers for up to 3 years and that would be
9 monitored by the agency every 6 months while in effect.
10 (j)(g) Other remedies as permitted by law to effect
11 the recovery of a fine or overpayment.
12
13 The Secretary of Health Care Administration may make a
14 determination that imposition of a sanction or disincentive is
15 not in the best interest of the Medicaid program, in which
16 case a sanction or disincentive shall not be imposed.
17 (16) In determining the appropriate administrative
18 sanction to be applied, or the duration of any suspension or
19 termination, the agency shall consider:
20 (a) The seriousness and extent of the violation or
21 violations.
22 (b) Any prior history of violations by the provider
23 relating to the delivery of health care programs which
24 resulted in either a criminal conviction or in administrative
25 sanction or penalty.
26 (c) Evidence of continued violation within the
27 provider's management control of Medicaid statutes, rules,
28 regulations, or policies after written notification to the
29 provider of improper practice or instance of violation.
30 (d) The effect, if any, on the quality of medical care
31 provided to Medicaid recipients as a result of the acts of the
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 provider.
2 (e) Any action by a licensing agency respecting the
3 provider in any state in which the provider operates or has
4 operated.
5 (f) The apparent impact on access by recipients to
6 Medicaid services if the provider is suspended or terminated,
7 in the best judgment of the agency.
8
9 The agency shall document the basis for all sanctioning
10 actions and recommendations.
11 (17) The agency may take action to sanction, suspend,
12 or terminate a particular provider working for a group
13 provider, and may suspend or terminate Medicaid participation
14 at a specific location, rather than or in addition to taking
15 action against an entire group.
16 (18) The agency shall establish a process for
17 conducting followup reviews of a sampling of providers who
18 have a history of overpayment under the Medicaid program.
19 This process must consider the magnitude of previous fraud or
20 abuse and the potential effect of continued fraud or abuse on
21 Medicaid costs.
22 (19) In making a determination of overpayment to a
23 provider, the agency must use accepted and valid auditing,
24 accounting, analytical, statistical, or peer-review methods,
25 or combinations thereof. Appropriate statistical methods may
26 include, but are not limited to, sampling and extension to the
27 population, parametric and nonparametric statistics, tests of
28 hypotheses, and other generally accepted statistical methods.
29 Appropriate analytical methods may include, but are not
30 limited to, reviews to determine variances between the
31 quantities of products that a provider had on hand and
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Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 available to be purveyed to Medicaid recipients during the
2 review period and the quantities of the same products paid for
3 by the Medicaid program for the same period, taking into
4 appropriate consideration sales of the same products to
5 non-Medicaid customers during the same period. In meeting its
6 burden of proof in any administrative or court proceeding, the
7 agency may introduce the results of such statistical methods
8 as evidence of overpayment.
9 (20) When making a determination that an overpayment
10 has occurred, the agency shall prepare and issue an audit
11 report to the provider showing the calculation of
12 overpayments.
13 (21) The audit report, supported by agency work
14 papers, showing an overpayment to a provider constitutes
15 evidence of the overpayment. A provider may not present or
16 elicit testimony, either on direct examination or
17 cross-examination in any court or administrative proceeding,
18 regarding the purchase or acquisition by any means of drugs,
19 goods, or supplies; sales or divestment by any means of drugs,
20 goods, or supplies; or inventory of drugs, goods, or supplies,
21 unless such acquisition, sales, divestment, or inventory is
22 documented by written invoices, written inventory records, or
23 other competent written documentary evidence maintained in the
24 normal course of the provider's business. Notwithstanding the
25 applicable rules of discovery, all documentation that will be
26 offered as evidence at an administrative hearing on a Medicaid
27 overpayment must be exchanged by all parties at least 14 days
28 before the administrative hearing or must be excluded from
29 consideration.
30 (22)(a) In an audit or investigation of a violation
31 committed by a provider which is conducted pursuant to this
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Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 section, the agency is entitled to recover all investigative,
2 legal, and expert witness costs if the agency's findings were
3 not contested by the provider or, if contested, the agency
4 ultimately prevailed.
5 (b) The agency has the burden of documenting the
6 costs, which include salaries and employee benefits and
7 out-of-pocket expenses. The amount of costs that may be
8 recovered must be reasonable in relation to the seriousness of
9 the violation and must be set taking into consideration the
10 financial resources, earning ability, and needs of the
11 provider, who has the burden of demonstrating such factors.
12 (c) The provider may pay the costs over a period to be
13 determined by the agency if the agency determines that an
14 extreme hardship would result to the provider from immediate
15 full payment. Any default in payment of costs may be
16 collected by any means authorized by law.
17 (23) If the agency imposes an administrative sanction
18 under this section upon any provider or other person who is
19 regulated by another state entity, the agency shall notify
20 that other entity of the imposition of the sanction. Such
21 notification must include the provider's or person's name and
22 license number and the specific reasons for sanction.
23 (24)(a) The agency may withhold Medicaid payments, in
24 whole or in part, to a provider upon receipt of reliable
25 evidence that the circumstances giving rise to the need for a
26 withholding of payments involve fraud, willful
27 misrepresentation, or abuse under the Medicaid program, or a
28 crime committed while rendering goods or services to Medicaid
29 recipients, pending completion of legal proceedings. If it is
30 determined that fraud, willful misrepresentation, abuse, or a
31 crime did not occur, the payments withheld must be paid to the
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 provider within 14 days after such determination with interest
2 at the rate of 10 percent a year. Any money withheld in
3 accordance with this paragraph shall be placed in a suspended
4 account, readily accessible to the agency, so that any payment
5 ultimately due the provider shall be made within 14 days.
6 (b) Overpayments owed to the agency bear interest at
7 the rate of 10 percent per year from the date of determination
8 of the overpayment by the agency, and payment arrangements
9 must be made at the conclusion of legal proceedings. A
10 provider who does not enter into or adhere to an agreed-upon
11 repayment schedule may be terminated by the agency for
12 nonpayment or partial payment.
13 (c) The agency, upon entry of a final agency order, a
14 judgment or order of a court of competent jurisdiction, or a
15 stipulation or settlement, may collect the moneys owed by all
16 means allowable by law, including, but not limited to,
17 notifying any fiscal intermediary of Medicare benefits that
18 the state has a superior right of payment. Upon receipt of
19 such written notification, the Medicare fiscal intermediary
20 shall remit to the state the sum claimed.
21 (25) The agency may impose administrative sanctions
22 against a Medicaid recipient, or the agency may seek any other
23 remedy provided by law, including, but not limited to, the
24 remedies provided in s. 812.035, if the agency finds that a
25 recipient has engaged in solicitation in violation of s.
26 409.920 or that the recipient has otherwise abused the
27 Medicaid program.
28 (26) When the Agency for Health Care Administration
29 has made a probable cause determination and alleged that an
30 overpayment to a Medicaid provider has occurred, the agency,
31 after notice to the provider, may:
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 (a) Withhold, and continue to withhold during the
2 pendency of an administrative hearing pursuant to chapter 120,
3 any medical assistance reimbursement payments until such time
4 as the overpayment is recovered, unless within 30 days after
5 receiving notice thereof the provider:
6 1. Makes repayment in full; or
7 2. Establishes a repayment plan that is satisfactory
8 to the Agency for Health Care Administration.
9 (b) Withhold, and continue to withhold during the
10 pendency of an administrative hearing pursuant to chapter 120,
11 medical assistance reimbursement payments if the terms of a
12 repayment plan are not adhered to by the provider.
13
14 If a provider requests an administrative hearing pursuant to
15 chapter 120, such hearing must be conducted within 90 days
16 following receipt by the provider of the final audit report,
17 absent exceptionally good cause shown as determined by the
18 administrative law judge or hearing officer. Upon issuance of
19 a final order, the balance outstanding of the amount
20 determined to constitute the overpayment shall become due. Any
21 withholding of payments by the Agency for Health Care
22 Administration pursuant to this section shall be limited so
23 that the monthly medical assistance payment is not reduced by
24 more than 10 percent.
25 (27) Venue for all Medicaid program integrity
26 overpayment cases shall lie in Leon County, at the discretion
27 of the agency.
28 (28) Notwithstanding other provisions of law, the
29 agency and the Medicaid Fraud Control Unit of the Department
30 of Legal Affairs may review a provider's non-Medicaid-related
31 records in order to determine the total output of a provider's
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 practice to reconcile quantities of goods or services billed
2 to Medicaid against quantities of goods or services used in
3 the provider's total practice.
4 (29) The agency may terminate a provider's
5 participation in the Medicaid program if the provider fails to
6 reimburse an overpayment that has been determined by final
7 order within 35 days after the date of the final order, unless
8 the provider and the agency have entered into a repayment
9 agreement. If the final order is overturned on appeal, the
10 provider shall be reinstated.
11 (30) If a provider requests an administrative hearing
12 pursuant to chapter 120, such hearing must be conducted within
13 90 days following assignment of an administrative law judge,
14 absent exceptionally good cause shown as determined by the
15 administrative law judge or hearing officer. Upon issuance of
16 a final order, the outstanding balance of the amount
17 determined to constitute the overpayment shall become due. If
18 a provider fails to make payments in full, fails to enter into
19 a satisfactory repayment plan, or fails to comply with the
20 terms of a repayment plan or settlement agreement, the agency
21 may withhold all medical assistance reimbursement payments
22 until the amount due is paid in full.
23 (31) Duly authorized agents and employees of the
24 agency and the Medicaid Fraud Control Unit of the Department
25 of Legal Affairs shall have the power to inspect, at all
26 reasonable hours and upon proper notice, the records of any
27 pharmacy, wholesale establishment, or manufacturer, or any
28 other place in the state in which drugs and medical supplies
29 are manufactured, packed, packaged, made, stored, sold, or
30 kept for sale, for the purpose of verifying the amount of
31 drugs and medical supplies ordered, delivered, or purchased by
61
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 a provider.
2 Section 19. Subsections (7) and (8) of section
3 409.920, Florida Statutes, are amended to read:
4 409.920 Medicaid provider fraud.--
5 (7) The Attorney General shall conduct a statewide
6 program of Medicaid fraud control. To accomplish this purpose,
7 the Attorney General shall:
8 (a) Investigate the possible criminal violation of any
9 applicable state law pertaining to fraud in the administration
10 of the Medicaid program, in the provision of medical
11 assistance, or in the activities of providers of health care
12 under the Medicaid program.
13 (b) Investigate the alleged abuse or neglect of
14 patients in health care facilities receiving payments under
15 the Medicaid program, in coordination with the agency.
16 (c) Investigate the alleged misappropriation of
17 patients' private funds in health care facilities receiving
18 payments under the Medicaid program.
19 (d) Refer to the Office of Statewide Prosecution or
20 the appropriate state attorney all violations indicating a
21 substantial potential for criminal prosecution.
22 (e) Refer to the agency all suspected abusive
23 activities not of a criminal or fraudulent nature.
24 (f) Refer to the agency for collection each instance
25 of overpayment to a provider of health care under the Medicaid
26 program which is discovered during the course of an
27 investigation.
28 (f)(g) Safeguard the privacy rights of all individuals
29 and provide safeguards to prevent the use of patient medical
30 records for any reason beyond the scope of a specific
31 investigation for fraud or abuse, or both, without the
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 patient's written consent.
2 (g) Publicize to state employees and the public the
3 ability of persons to bring suit under the provisions of the
4 Florida False Claims Act and the potential for the persons
5 bringing a civil action under the Florida False Claims Act to
6 obtain a monetary award.
7 (8) In carrying out the duties and responsibilities
8 under this section subsection, the Attorney General may:
9 (a) Enter upon the premises of any health care
10 provider, excluding a physician, participating in the Medicaid
11 program to examine all accounts and records that may, in any
12 manner, be relevant in determining the existence of fraud in
13 the Medicaid program, to investigate alleged abuse or neglect
14 of patients, or to investigate alleged misappropriation of
15 patients' private funds. A participating physician is required
16 to make available any accounts or records that may, in any
17 manner, be relevant in determining the existence of fraud in
18 the Medicaid program. The accounts or records of a
19 non-Medicaid patient may not be reviewed by, or turned over
20 to, the Attorney General without the patient's written
21 consent.
22 (b) Subpoena witnesses or materials, including medical
23 records relating to Medicaid recipients, within or outside the
24 state and, through any duly designated employee, administer
25 oaths and affirmations and collect evidence for possible use
26 in either civil or criminal judicial proceedings.
27 (c) Request and receive the assistance of any state
28 attorney or law enforcement agency in the investigation and
29 prosecution of any violation of this section.
30 (d) Seek any civil remedy provided by law, including,
31 but not limited to, the remedies provided in ss.
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 68.081-68.092, s. 812.035, and this chapter.
2 (e) Refer to the agency for collection each instance
3 of overpayment to a provider of health care under the Medicaid
4 program which is discovered during the course of an
5 investigation.
6 Section 20. Subsection (28) of section 393.063,
7 Florida Statutes, is amended to read:
8 393.063 Definitions.--For the purposes of this
9 chapter:
10 (28) "Intermediate care facility for the
11 developmentally disabled" or "ICF/DD" means a
12 state-owned-and-operated residential facility licensed and
13 certified in accordance with state law, and certified by the
14 Federal Government pursuant to the Social Security Act, as a
15 provider of Medicaid services to persons who are
16 developmentally disabled mentally retarded or who have related
17 conditions. The capacity of such a facility shall not be more
18 than 120 clients.
19 Section 21. Section 400.965, Florida Statutes, is
20 amended to read:
21 400.965 Action by agency against licensee; grounds.--
22 (1) Any of the following conditions constitute grounds
23 for action by the agency against a licensee:
24 (a) A misrepresentation of a material fact in the
25 application;
26 (b) The commission of an intentional or negligent act
27 materially affecting the health or safety of residents of the
28 facility;
29 (c) A violation of any provision of this part or rules
30 adopted under this part; or
31 (d) The commission of any act constituting a ground
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 upon which application for a license may be denied.
2 (2) If the agency has a reasonable belief that any of
3 such conditions exists, it shall:
4 (a) In the case of an applicant for original
5 licensure, deny the application.
6 (b) In the case of an applicant for relicensure or a
7 current licensee, take administrative action as provided in s.
8 400.968 or s. 400.969 or injunctive action as authorized by s.
9 400.963.
10 (c) In the case of a facility operating without a
11 license, take injunctive action as authorized in s. 400.963.
12 Section 22. Subsection (4) of section 400.968, Florida
13 Statutes, is renumbered as section 400.969, Florida Statutes,
14 and amended to read:
15 400.969 Violation of part; penalties.--
16 (1)(4)(a) Except as provided in s. 400.967(3), a
17 violation of any provision of this part section or rules
18 adopted by the agency under this part section is punishable by
19 payment of an administrative or civil penalty not to exceed
20 $5,000.
21 (2)(b) A violation of this part section or of rules
22 adopted under this part section is a misdemeanor of the first
23 degree, punishable as provided in s. 775.082 or s. 775.083.
24 Each day of a continuing violation is a separate offense.
25 Section 23. By January 1, 2003, the Agency for Health
26 Care Administration shall make recommendations to the
27 Legislature as to limits in the amount of home office
28 management and administrative fees which should be allowable
29 for reimbursement for Medicaid providers whose rates are set
30 on a cost-reimbursement basis.
31 Section 24. Except as otherwise provided herein, this
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 act shall take effect upon becoming a law
2
3
4 ================ T I T L E A M E N D M E N T ===============
5 And the title is amended as follows:
6 On page 1, line 2, through page 3, line 27,
7 remove
8 all of said lines
9
10 and insert:
11 An act relating to health care; amending s.
12 16.59, F.S.; requiring certain collocation and
13 coordination of the Medicaid Fraud Control Unit
14 of the Department of Legal Affairs and the
15 Medicaid program integrity program; amending s.
16 112.3187, F.S.; revising procedures and
17 requirements relating to whistle-blower
18 protection for reporting Medicaid fraud or
19 abuse; creating s. 408.831, F.S.; authorizing
20 the Agency for Health Care Administration to
21 take action against a regulated entity under
22 certain circumstances; reenacting s.
23 409.8132(4), F.S., to incorporate amendments to
24 ss. 409.902, 409.907, 409.908, and 409.913,
25 F.S., in references thereto; amending s.
26 409.902, F.S.; requiring consent for release of
27 medical records to the agency and the Medicaid
28 Fraud Control Unit as a condition of Medicaid
29 eligibility; amending s. 409.904, F.S.;
30 revising eligibility standards for certain
31 Medicaid optional medical assistance; amending
66
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 s. 409.906, F.S.; revising guidelines for
2 payment for certain services; revising
3 eligibility for certain Medicaid services
4 amending s. 409.9065, F.S.; revising
5 eligibility standards for the pharmaceutical
6 expense assistance program; amending s.
7 409.907, F.S.; prescribing additional
8 requirements with respect to Medicaid provider
9 enrollment; requiring the agency to deny a
10 provider's application under certain
11 circumstances; providing a finding of important
12 state interest; amending s. 409.908, F.S.;
13 authorizing the agency to withhold provider
14 reimbursements if certain requirements for cost
15 reporting are not met; amending s. 409.910,
16 F.S.; revising requirements for the
17 distribution of funds recovered from third
18 parties liable for payments for medical care
19 furnished to Medicaid recipients or recovered
20 from overpayments, to provide for distributions
21 to counties and local taxing districts;
22 amending s. 409.9116, F.S.; revising
23 applicability of the disproportionate
24 share/financial assistance program for rural
25 hospitals; amending s. 409.912, F.S.; providing
26 requirements for contracts for Medicaid
27 behavioral health care services; amending s.
28 409.9122, F.S.; revising procedures relating to
29 assignment of a Medicaid recipient to a managed
30 care plan or MediPass provider; amending s.
31 409.913, F.S.; requiring the agency and the
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HOUSE AMENDMENT
Bill No. HB 1975, 1st Eng.
Amendment No. ___ (for drafter's use only)
1 Medicaid Fraud Control Unit to annually submit
2 a joint report to the Legislature; defining the
3 term "complaint" with respect to Medicaid fraud
4 or abuse; specifying additional requirements
5 for the Medicaid program integrity program and
6 the Medicaid Fraud Control Unit; requiring
7 imposition of sanctions or disincentives,
8 except under certain circumstances; providing
9 additional sanctions and disincentives;
10 providing additional grounds for termination of
11 a provider's participation in the Medicaid
12 program; providing additional requirements for
13 administrative hearings; providing additional
14 grounds for withholding payments to a provider;
15 authorizing the agency and the Medicaid Fraud
16 Control Unit to review certain records;
17 amending s. 409.920, F.S.; providing additional
18 duties of the Attorney General with respect to
19 Medicaid fraud control; amending s. 393.063,
20 F.S.; revising definition of the term
21 "intermediate care facility for the
22 developmentally disabled" for purposes of ch.
23 393, F.S.; amending ss. 400.965 and 400.968,
24 F.S.; providing penalties for violation of pt.
25 XI of ch. 400, F.S., relating to intermediate
26 care facilities for developmentally disabled
27 persons; requiring the agency to make
28 recommendations to the Legislature regarding
29 limitations on certain Medicaid provider
30 reimbursements; providing effective dates.
31
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