House Bill hb1975
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Florida House of Representatives - 2002 HB 1975
By the Fiscal Responsibility Council and Representative
Murman
1 A bill to be entitled
2 An act relating to health care; amending s.
3 16.59, F.S.; requiring certain collocation and
4 coordination of the Medicaid Fraud Control Unit
5 of the Department of Legal Affairs and the
6 Medicaid program integrity program; amending s.
7 112.3187, F.S.; revising procedures and
8 requirements relating to whistle-blower
9 protection for reporting Medicaid fraud or
10 abuse; creating s. 408.831, F.S.; authorizing
11 the Agency for Health Care Administration to
12 take action against a regulated entity under
13 certain circumstances; reenacting s.
14 409.8132(4), F.S., to incorporate amendments to
15 ss. 409.902, 409.907, 409.908, and 409.913,
16 F.S., in references thereto; amending s.
17 409.902, F.S.; requiring consent for release of
18 medical records to the agency and the Medicaid
19 Fraud Control Unit as a condition of Medicaid
20 eligibility; amending s. 409.904, F.S.;
21 revising eligibility standards for certain
22 Medicaid optional medical assistance; amending
23 s. 409.9065, F.S.; revising eligibility
24 standards for the pharmaceutical expense
25 assistance program; amending s. 409.907, F.S.;
26 prescribing additional requirements with
27 respect to Medicaid provider enrollment;
28 requiring the agency to deny a provider's
29 application under certain circumstances;
30 providing a finding of important state
31 interest; amending s. 409.908, F.S.;
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1 authorizing the agency to withhold provider
2 reimbursements if certain requirements for cost
3 reporting are not met; amending s. 409.910,
4 F.S.; revising requirements for the
5 distribution of funds recovered from third
6 parties liable for payments for medical care
7 furnished to Medicaid recipients or recovered
8 from overpayments, to provide for distributions
9 to counties and local taxing districts;
10 amending s. 409.9116, F.S.; revising
11 applicability of the disproportionate
12 share/financial assistance program for rural
13 hospitals; amending s. 409.912, F.S.; providing
14 requirements for contracts for Medicaid
15 behavioral health care services; amending s.
16 409.9122, F.S.; revising procedures relating to
17 assignment of a Medicaid recipient to a managed
18 care plan or MediPass provider; amending s.
19 409.913, F.S.; requiring the agency and the
20 Medicaid Fraud Control Unit to annually submit
21 a joint report to the Legislature; defining the
22 term "complaint" with respect to Medicaid fraud
23 or abuse; specifying additional requirements
24 for the Medicaid program integrity program and
25 the Medicaid Fraud Control Unit; requiring
26 imposition of sanctions or disincentives,
27 except under certain circumstances; providing
28 additional sanctions and disincentives;
29 providing additional grounds for termination of
30 a provider's participation in the Medicaid
31 program; providing additional requirements for
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1 administrative hearings; providing additional
2 grounds for withholding payments to a provider;
3 authorizing the agency and the Medicaid Fraud
4 Control Unit to review certain records;
5 amending s. 409.915, F.S.; revising a
6 limitation on the county contribution to
7 Medicaid costs; amending s. 409.920, F.S.;
8 providing additional duties of the Attorney
9 General with respect to Medicaid fraud control;
10 amending s. 624.91, F.S.; revising duties of
11 the Florida Healthy Kids Corporation with
12 respect to annual determination of
13 participation in the Healthy Kids Program;
14 creating s. 624.915, F.S.; prescribing duties
15 of the corporation in establishing local match
16 requirements; amending s. 393.063, F.S.;
17 revising definition of the term "intermediate
18 care facility for the developmentally disabled"
19 for purposes of ch. 393, F.S.; amending ss.
20 400.965 and 400.968, F.S.; providing penalties
21 for violation of pt. XI of ch. 400, F.S.,
22 relating to intermediate care facilities for
23 developmentally disabled persons; requiring the
24 agency to make recommendations to the
25 Legislature regarding limitations on certain
26 Medicaid provider reimbursements; providing
27 effective dates.
28
29 Be It Enacted by the Legislature of the State of Florida:
30
31
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1 Section 1. Section 16.59, Florida Statutes, is amended
2 to read:
3 16.59 Medicaid fraud control.--There is created in the
4 Department of Legal Affairs the Medicaid Fraud Control Unit,
5 which may investigate all violations of s. 409.920 and any
6 criminal violations discovered during the course of those
7 investigations. The Medicaid Fraud Control Unit may refer any
8 criminal violation so uncovered to the appropriate prosecuting
9 authority. Offices of the Medicaid Fraud Control Unit and the
10 offices of the Agency for Health Care Administration Medicaid
11 program integrity program shall, to the extent possible, be
12 colocated. The agency and the Department of Legal Affairs
13 shall conduct joint training and other joint activities
14 designed to increase communication and coordination in
15 recovering overpayments.
16 Section 2. Subsections (3), (5), and (7) of section
17 112.3187, Florida Statutes, are amended to read:
18 112.3187 Adverse action against employee for
19 disclosing information of specified nature prohibited;
20 employee remedy and relief.--
21 (3) DEFINITIONS.--As used in this act, unless
22 otherwise specified, the following words or terms shall have
23 the meanings indicated:
24 (a) "Agency" means any state, regional, county, local,
25 or municipal government entity, whether executive, judicial,
26 or legislative; any official, officer, department, division,
27 bureau, commission, authority, or political subdivision
28 therein; or any public school, community college, or state
29 university.
30 (b) "Employee" means a person who performs services
31 for, and under the control and direction of, or contracts
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1 with, an agency or independent contractor for wages or other
2 remuneration.
3 (c) "Adverse personnel action" means the discharge,
4 suspension, transfer, or demotion of any employee or the
5 withholding of bonuses, the reduction in salary or benefits,
6 or any other adverse action taken against an employee within
7 the terms and conditions of employment by an agency or
8 independent contractor.
9 (d) "Independent contractor" means a person, other
10 than an agency, engaged in any business and who enters into a
11 contract or provider agreement with an agency.
12 (e) "Gross mismanagement" means a continuous pattern
13 of managerial abuses, wrongful or arbitrary and capricious
14 actions, or fraudulent or criminal conduct which may have a
15 substantial adverse economic impact.
16 (5) NATURE OF INFORMATION DISCLOSED.--The information
17 disclosed under this section must include:
18 (a) Any violation or suspected violation of any
19 federal, state, or local law, rule, or regulation committed by
20 an employee or agent of an agency or independent contractor
21 which creates and presents a substantial and specific danger
22 to the public's health, safety, or welfare.
23 (b) Any act or suspected act of gross mismanagement,
24 malfeasance, misfeasance, gross waste of public funds,
25 suspected or actual Medicaid fraud or abuse, or gross neglect
26 of duty committed by an employee or agent of an agency or
27 independent contractor.
28 (7) EMPLOYEES AND PERSONS PROTECTED.--This section
29 protects employees and persons who disclose information on
30 their own initiative in a written and signed complaint; who
31 are requested to participate in an investigation, hearing, or
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1 other inquiry conducted by any agency or federal government
2 entity; who refuse to participate in any adverse action
3 prohibited by this section; or who initiate a complaint
4 through the whistle-blower's hotline or the hotline of the
5 Medicaid Fraud Control Unit of the Department of Legal
6 Affairs; or employees who file any written complaint to their
7 supervisory officials or employees who submit a complaint to
8 the Chief Inspector General in the Executive Office of the
9 Governor, to the employee designated as agency inspector
10 general under s. 112.3189(1), or to the Florida Commission on
11 Human Relations. The provisions of this section may not be
12 used by a person while he or she is under the care, custody,
13 or control of the state correctional system or, after release
14 from the care, custody, or control of the state correctional
15 system, with respect to circumstances that occurred during any
16 period of incarceration. No remedy or other protection under
17 ss. 112.3187-112.31895 applies to any person who has committed
18 or intentionally participated in committing the violation or
19 suspected violation for which protection under ss.
20 112.3187-112.31895 is being sought.
21 Section 3. Section 408.831, Florida Statutes, is
22 created to read:
23 408.831 Denial of application; suspension or
24 revocation of license, registration, or certificate.--
25 (1) In addition to any other remedies provided by law,
26 the agency may deny each application or suspend or revoke each
27 license, registration, or certificate of entities regulated or
28 licensed by it:
29 (a) If the applicant, licensee, registrant, or
30 certificateholder, or, in the case of a corporation,
31 partnership, or other business entity, if any officer,
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1 director, agent, or managing employee of that business entity
2 or any affiliated person, partner, or shareholder having an
3 ownership interest equal to 5 percent or greater in that
4 business entity, has failed to pay all outstanding fines,
5 liens, or overpayments assessed by final order of the agency
6 or final order of the Centers for Medicare and Medicaid
7 Services unless a repayment plan is approved by the agency; or
8 (b) For failure to comply with any repayment plan.
9 (2) For all legal proceedings that may result from a
10 denial, suspension, or revocation under this section,
11 testimony or documentation from the financial entity charged
12 with monitoring such payment shall constitute evidence of the
13 failure to pay an outstanding fine, lien, or overpayment and
14 shall be sufficient grounds for the denial, suspension, or
15 revocation.
16 (3) This section provides standards of enforcement
17 applicable to all entities licensed or regulated by the Agency
18 for Health Care Administration. This section controls over any
19 conflicting provisions of chapters 39, 381, 383, 390, 391,
20 393, 394, 395, 400, 408, 468, 483, and 641 or rules adopted
21 pursuant to those chapters.
22 Section 4. For the purpose of incorporating the
23 amendments made by this act to sections 409.902, 409.907,
24 409.908, and 409.913, Florida Statutes, in references thereto,
25 subsection (4) of section 409.8132, Florida Statutes, is
26 reenacted to read:
27 409.8132 Medikids program component.--
28 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
29 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
30 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
31 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
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1 apply to the administration of the Medikids program component
2 of the Florida Kidcare program, except that s. 409.9122
3 applies to Medikids as modified by the provisions of
4 subsection (7).
5 Section 5. Section 409.902, Florida Statutes, is
6 amended to read:
7 409.902 Designated single state agency; payment
8 requirements; program title; release of medical records.--The
9 Agency for Health Care Administration is designated as the
10 single state agency authorized to make payments for medical
11 assistance and related services under Title XIX of the Social
12 Security Act. These payments shall be made, subject to any
13 limitations or directions provided for in the General
14 Appropriations Act, only for services included in the program,
15 shall be made only on behalf of eligible individuals, and
16 shall be made only to qualified providers in accordance with
17 federal requirements for Title XIX of the Social Security Act
18 and the provisions of state law. This program of medical
19 assistance is designated the "Medicaid program." The
20 Department of Children and Family Services is responsible for
21 Medicaid eligibility determinations, including, but not
22 limited to, policy, rules, and the agreement with the Social
23 Security Administration for Medicaid eligibility
24 determinations for Supplemental Security Income recipients, as
25 well as the actual determination of eligibility. As a
26 condition of Medicaid eligibility, the Agency for Health Care
27 Administration and the Department of Children and Family
28 Services shall ensure that each recipient of Medicaid consents
29 to the release of her or his medical records to the Agency for
30 Health Care Administration and the Medicaid Fraud Control Unit
31 of the Department of Legal Affairs.
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1 Section 6. Effective July 1, 2002, subsection (1) of
2 section 409.904, Florida Statutes, as amended by section 2 of
3 chapter 2001-377, Laws of Florida, is amended to read:
4 409.904 Optional payments for eligible persons.--The
5 agency may make payments for medical assistance and related
6 services on behalf of the following persons who are determined
7 to be eligible subject to the income, assets, and categorical
8 eligibility tests set forth in federal and state law. Payment
9 on behalf of these Medicaid eligible persons is subject to the
10 availability of moneys and any limitations established by the
11 General Appropriations Act or chapter 216.
12 (1) A person who is age 65 or older or is determined
13 to be disabled, whose income is at or below 90 88 percent of
14 federal poverty level, and whose assets do not exceed
15 established limitations.
16 Section 7. Present subsections (8) and (10) of section
17 409.904, Florida Statutes, are amended, present subsections
18 (9), (10), and (11) are renumbered as subsections (10), (11),
19 and (12), respectively, and a new subsection (9) is added to
20 said section, to read:
21 409.904 Optional payments for eligible persons.--The
22 agency may make payments for medical assistance and related
23 services on behalf of the following persons who are determined
24 to be eligible subject to the income, assets, and categorical
25 eligibility tests set forth in federal and state law. Payment
26 on behalf of these Medicaid eligible persons is subject to the
27 availability of moneys and any limitations established by the
28 General Appropriations Act or chapter 216.
29 (8) An unborn child or a child under 1 year of age who
30 lives in a family that has an income above 150 185 percent but
31 not in excess of 200 percent of the most recently published
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1 federal poverty level, but which is at or below 200 percent of
2 such poverty level. Countable income shall be determined in
3 accordance with state and federal regulation. For an unborn
4 child, coverage is dependent upon federal approval of coverage
5 through Title XXI of the Social Security Act. In determining
6 the eligibility of such child, an assets test is not required.
7 A child who is eligible for Medicaid under this subsection
8 must be offered the opportunity, subject to federal rules, to
9 be made presumptively eligible.
10 (9) A pregnant woman for the duration of her pregnancy
11 and for the postpartum period as defined in federal law and
12 regulation, who has an income above 150 percent but not in
13 excess of 185 percent of the federal poverty level. Countable
14 income shall be determined in accordance with state and
15 federal regulation. A pregnant woman who applies for
16 eligibility for the Medicaid program shall be offered the
17 opportunity, subject to federal regulations, to be made
18 presumptively eligible. Coverage for a pregnant woman during
19 her pregnancy shall not be available should coverage become
20 available under Title XXI of the Social Security Act as
21 provided in subsection (8).
22 (11)(10)(a) Eligible women with incomes at or below
23 200 percent of the federal poverty level and under age 65, for
24 cancer treatment pursuant to the federal Breast and Cervical
25 Cancer Prevention and Treatment Act of 2000, screened through
26 the Mary Brogan National Breast and Cervical Cancer Early
27 Detection Program established under s. 381.93.
28 (b) A woman who has not attained 65 years of age and
29 who has been screened for breast or cervical cancer by a
30 qualified entity under the Mary Brogan Breast and Cervical
31 Cancer Early Detection Program of the Department of Health and
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1 needs treatment for breast or cervical cancer and is not
2 otherwise covered under creditable coverage, as defined in s.
3 2701(c) of the Public Health Service Act. For purposes of this
4 subsection, the term "qualified entity" means a county public
5 health department or other entity that has contracted with the
6 Department of Health to provide breast and cervical cancer
7 screening services paid for under this act. In determining the
8 eligibility of such a woman, an assets test is not required. A
9 presumptive eligibility period begins on the date on which all
10 eligibility criteria appear to be met and ends on the date
11 determination is made with respect to the eligibility of such
12 woman for services under the state plan or, in the case of
13 such a woman who does not file an application, by the last day
14 of the month following the month in which the presumptive
15 eligibility determination is made. A woman is eligible until
16 she gains creditable coverage, until treatment is no longer
17 necessary, or until attainment of 65 years of age.
18 Section 8. Effective July 1, 2002, subsection (2) of
19 section 409.9065, Florida Statutes, is amended to read:
20 409.9065 Pharmaceutical expense assistance.--
21 (2) ELIGIBILITY.--Eligibility for the program is
22 limited to those individuals who qualify for limited
23 assistance under the Florida Medicaid program as a result of
24 being dually eligible for both Medicare and Medicaid, but
25 whose limited assistance or Medicare coverage does not include
26 any pharmacy benefit. To the extent that funds are
27 appropriated, specifically eligible are low-income senior
28 citizens who:
29 (a) Are Florida residents age 65 and over;
30 (b) Have an income between 90 and 120 percent of the
31 federal poverty level, or an income between 90 and 150 percent
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1 of the federal poverty level if the Federal Government raises
2 the Medicaid match to 150 percent of the federal poverty
3 level;
4 (c) Are eligible for both Medicare and Medicaid;
5 (d) Are not enrolled in a Medicare health maintenance
6 organization that provides a pharmacy benefit; and
7 (e) Request to be enrolled in the program.
8 Section 9. Subsections (7) and (9) of section 409.907,
9 Florida Statutes, as amended by section 6 of chapter 2001-377,
10 Laws of Florida, are amended to read:
11 409.907 Medicaid provider agreements.--The agency may
12 make payments for medical assistance and related services
13 rendered to Medicaid recipients only to an individual or
14 entity who has a provider agreement in effect with the agency,
15 who is performing services or supplying goods in accordance
16 with federal, state, and local law, and who agrees that no
17 person shall, on the grounds of handicap, race, color, or
18 national origin, or for any other reason, be subjected to
19 discrimination under any program or activity for which the
20 provider receives payment from the agency.
21 (7) The agency may require, as a condition of
22 participating in the Medicaid program and before entering into
23 the provider agreement, that the provider submit information,
24 in an initial and any required renewal applications,
25 concerning the professional, business, and personal background
26 of the provider and permit an onsite inspection of the
27 provider's service location by agency staff or other personnel
28 designated by the agency to perform this function. After
29 receipt of the fully completed application of a new provider,
30 the agency shall perform random onsite inspection of the
31 provider's service location to assist in determining the
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1 applicant's ability to provide the services that the applicant
2 is proposing to provide for Medicaid reimbursement. The agency
3 is not required to perform an onsite inspection of a provider
4 or program that is licensed by the agency or the Department of
5 Health. As a continuing condition of participation in the
6 Medicaid program, a provider shall immediately notify the
7 agency of any current or pending bankruptcy filing. Before
8 entering into the provider agreement, or as a condition of
9 continuing participation in the Medicaid program, the agency
10 may also require that Medicaid providers reimbursed on a
11 fee-for-services basis or fee schedule basis which is not
12 cost-based, post a surety bond not to exceed $50,000 or the
13 total amount billed by the provider to the program during the
14 current or most recent calendar year, whichever is greater.
15 For new providers, the amount of the surety bond shall be
16 determined by the agency based on the provider's estimate of
17 its first year's billing. If the provider's billing during the
18 first year exceeds the bond amount, the agency may require the
19 provider to acquire an additional bond equal to the actual
20 billing level of the provider. A provider's bond shall not
21 exceed $50,000 if a physician or group of physicians licensed
22 under chapter 458, chapter 459, or chapter 460 has a 50
23 percent or greater ownership interest in the provider or if
24 the provider is an assisted living facility licensed under
25 part III of chapter 400. The bonds permitted by this section
26 are in addition to the bonds referenced in s. 400.179(4)(d).
27 If the provider is a corporation, partnership, association, or
28 other entity, the agency may require the provider to submit
29 information concerning the background of that entity and of
30 any principal of the entity, including any partner or
31 shareholder having an ownership interest in the entity equal
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1 to 5 percent or greater, and any treating provider who
2 participates in or intends to participate in Medicaid through
3 the entity. The information must include:
4 (a) Proof of holding a valid license or operating
5 certificate, as applicable, if required by the state or local
6 jurisdiction in which the provider is located or if required
7 by the Federal Government.
8 (b) Information concerning any prior violation, fine,
9 suspension, termination, or other administrative action taken
10 under the Medicaid laws, rules, or regulations of this state
11 or of any other state or the Federal Government; any prior
12 violation of the laws, rules, or regulations relating to the
13 Medicare program; any prior violation of the rules or
14 regulations of any other public or private insurer; and any
15 prior violation of the laws, rules, or regulations of any
16 regulatory body of this or any other state.
17 (c) Full and accurate disclosure of any financial or
18 ownership interest that the provider, or any principal,
19 partner, or major shareholder thereof, may hold in any other
20 Medicaid provider or health care related entity or any other
21 entity that is licensed by the state to provide health or
22 residential care and treatment to persons.
23 (d) If a group provider, identification of all members
24 of the group and attestation that all members of the group are
25 enrolled in or have applied to enroll in the Medicaid program.
26 (9) Upon receipt of a completed, signed, and dated
27 application, and completion of any necessary background
28 investigation and criminal history record check, the agency
29 must either:
30 (a) Enroll the applicant as a Medicaid provider no
31 earlier than the effective date of the approval of the
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1 provider application. With respect to providers who were
2 recently granted a change of ownership and those who primarily
3 provide emergency medical services transportation or emergency
4 services and care pursuant to s. 401.45 or s. 395.1041, and
5 out-of-state providers, upon approval of the provider
6 application, the effective date of approval is considered to
7 be the date the agency receives the provider application; or
8 (b) Deny the application if the agency finds that it
9 is in the best interest of the Medicaid program to do so. The
10 agency may consider the factors listed in subsection (10), as
11 well as any other factor that could affect the effective and
12 efficient administration of the program, including, but not
13 limited to, the applicant's demonstrated ability to provide
14 services, conduct business, and operate a financially viable
15 concern; the current availability of medical care, services,
16 or supplies to recipients, taking into account geographic
17 location and reasonable travel time; the number of providers
18 of the same type already enrolled in the same geographic area;
19 and the credentials, experience, success, and patient outcomes
20 of the provider for the services that it is making application
21 to provide in the Medicaid program. The agency shall deny the
22 application if the agency finds that a provider; any officer,
23 director, agent, managing employee, or affiliated person; or
24 any partner or shareholder having an ownership interest of 5
25 percent or more in the provider if the provider is a
26 corporation, partnership, or other business entity has failed
27 to pay all outstanding fines or overpayments assessed by final
28 order of the agency or final order of the Centers for Medicare
29 and Medicaid Services, unless the provider agrees to a
30 repayment plan that includes withholding Medicaid
31 reimbursement until the amount due is paid in full.
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1 Section 10. The Legislature determines and declares
2 that this act fulfills an important state interest.
3 Section 11. Section 409.908, Florida Statutes, as
4 amended by section 7 of chapter 2001-377, Laws of Florida, is
5 amended to read:
6 409.908 Reimbursement of Medicaid providers.--Subject
7 to specific appropriations, the agency shall reimburse
8 Medicaid providers, in accordance with state and federal law,
9 according to methodologies set forth in the rules of the
10 agency and in policy manuals and handbooks incorporated by
11 reference therein. These methodologies may include fee
12 schedules, reimbursement methods based on cost reporting,
13 negotiated fees, competitive bidding pursuant to s. 287.057,
14 and other mechanisms the agency considers efficient and
15 effective for purchasing services or goods on behalf of
16 recipients. If a provider is reimbursed based on cost
17 reporting and fails to submit cost reports at the time
18 specified by the agency, the agency may withhold reimbursement
19 to the provider until a cost report is submitted that is
20 acceptable to the agency. Payment for Medicaid compensable
21 services made on behalf of Medicaid eligible persons is
22 subject to the availability of moneys and any limitations or
23 directions provided for in the General Appropriations Act or
24 chapter 216. Further, nothing in this section shall be
25 construed to prevent or limit the agency from adjusting fees,
26 reimbursement rates, lengths of stay, number of visits, or
27 number of services, or making any other adjustments necessary
28 to comply with the availability of moneys and any limitations
29 or directions provided for in the General Appropriations Act,
30 provided the adjustment is consistent with legislative intent.
31
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1 (1) Reimbursement to hospitals licensed under part I
2 of chapter 395 must be made prospectively or on the basis of
3 negotiation.
4 (a) Reimbursement for inpatient care is limited as
5 provided for in s. 409.905(5), except for:
6 1. The raising of rate reimbursement caps, excluding
7 rural hospitals.
8 2. Recognition of the costs of graduate medical
9 education.
10 3. Other methodologies recognized in the General
11 Appropriations Act.
12 4. Hospital inpatient rates shall be reduced by 6
13 percent effective July 1, 2001, and restored effective April
14 1, 2002.
15
16 During the years funds are transferred from the Department of
17 Health, any reimbursement supported by such funds shall be
18 subject to certification by the Department of Health that the
19 hospital has complied with s. 381.0403. The agency is
20 authorized to receive funds from state entities, including,
21 but not limited to, the Department of Health, local
22 governments, and other local political subdivisions, for the
23 purpose of making special exception payments, including
24 federal matching funds, through the Medicaid inpatient
25 reimbursement methodologies. Funds received from state
26 entities or local governments for this purpose shall be
27 separately accounted for and shall not be commingled with
28 other state or local funds in any manner. The agency may
29 certify all local governmental funds used as state match under
30 Title XIX of the Social Security Act, to the extent that the
31 identified local health care provider that is otherwise
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1 entitled to and is contracted to receive such local funds is
2 the benefactor under the state's Medicaid program as
3 determined under the General Appropriations Act and pursuant
4 to an agreement between the Agency for Health Care
5 Administration and the local governmental entity. The local
6 governmental entity shall use a certification form prescribed
7 by the agency. At a minimum, the certification form shall
8 identify the amount being certified and describe the
9 relationship between the certifying local governmental entity
10 and the local health care provider. The agency shall prepare
11 an annual statement of impact which documents the specific
12 activities undertaken during the previous fiscal year pursuant
13 to this paragraph, to be submitted to the Legislature no later
14 than January 1, annually.
15 (b) Reimbursement for hospital outpatient care is
16 limited to $1,500 per state fiscal year per recipient, except
17 for:
18 1. Such care provided to a Medicaid recipient under
19 age 21, in which case the only limitation is medical
20 necessity.
21 2. Renal dialysis services.
22 3. Other exceptions made by the agency.
23
24 The agency is authorized to receive funds from state entities,
25 including, but not limited to, the Department of Health, the
26 Board of Regents, local governments, and other local political
27 subdivisions, for the purpose of making payments, including
28 federal matching funds, through the Medicaid outpatient
29 reimbursement methodologies. Funds received from state
30 entities and local governments for this purpose shall be
31
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1 separately accounted for and shall not be commingled with
2 other state or local funds in any manner.
3 (c) Hospitals that provide services to a
4 disproportionate share of low-income Medicaid recipients, or
5 that participate in the regional perinatal intensive care
6 center program under chapter 383, or that participate in the
7 statutory teaching hospital disproportionate share program may
8 receive additional reimbursement. The total amount of payment
9 for disproportionate share hospitals shall be fixed by the
10 General Appropriations Act. The computation of these payments
11 must be made in compliance with all federal regulations and
12 the methodologies described in ss. 409.911, 409.9112, and
13 409.9113.
14 (d) The agency is authorized to limit inflationary
15 increases for outpatient hospital services as directed by the
16 General Appropriations Act.
17 (2)(a)1. Reimbursement to nursing homes licensed under
18 part II of chapter 400 and state-owned-and-operated
19 intermediate care facilities for the developmentally disabled
20 licensed under chapter 393 must be made prospectively.
21 2. Unless otherwise limited or directed in the General
22 Appropriations Act, reimbursement to hospitals licensed under
23 part I of chapter 395 for the provision of swing-bed nursing
24 home services must be made on the basis of the average
25 statewide nursing home payment, and reimbursement to a
26 hospital licensed under part I of chapter 395 for the
27 provision of skilled nursing services must be made on the
28 basis of the average nursing home payment for those services
29 in the county in which the hospital is located. When a
30 hospital is located in a county that does not have any
31 community nursing homes, reimbursement must be determined by
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1 averaging the nursing home payments, in counties that surround
2 the county in which the hospital is located. Reimbursement to
3 hospitals, including Medicaid payment of Medicare copayments,
4 for skilled nursing services shall be limited to 30 days,
5 unless a prior authorization has been obtained from the
6 agency. Medicaid reimbursement may be extended by the agency
7 beyond 30 days, and approval must be based upon verification
8 by the patient's physician that the patient requires
9 short-term rehabilitative and recuperative services only, in
10 which case an extension of no more than 15 days may be
11 approved. Reimbursement to a hospital licensed under part I of
12 chapter 395 for the temporary provision of skilled nursing
13 services to nursing home residents who have been displaced as
14 the result of a natural disaster or other emergency may not
15 exceed the average county nursing home payment for those
16 services in the county in which the hospital is located and is
17 limited to the period of time which the agency considers
18 necessary for continued placement of the nursing home
19 residents in the hospital.
20 (b) Subject to any limitations or directions provided
21 for in the General Appropriations Act, the agency shall
22 establish and implement a Florida Title XIX Long-Term Care
23 Reimbursement Plan (Medicaid) for nursing home care in order
24 to provide care and services in conformance with the
25 applicable state and federal laws, rules, regulations, and
26 quality and safety standards and to ensure that individuals
27 eligible for medical assistance have reasonable geographic
28 access to such care.
29 1. Changes of ownership or of licensed operator do not
30 qualify for increases in reimbursement rates associated with
31 the change of ownership or of licensed operator. The agency
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1 shall amend the Title XIX Long Term Care Reimbursement Plan to
2 provide that the initial nursing home reimbursement rates, for
3 the operating, patient care, and MAR components, associated
4 with related and unrelated party changes of ownership or
5 licensed operator filed on or after September 1, 2001, are
6 equivalent to the previous owner's reimbursement rate.
7 2. The agency shall amend the long-term care
8 reimbursement plan and cost reporting system to create direct
9 care and indirect care subcomponents of the patient care
10 component of the per diem rate. These two subcomponents
11 together shall equal the patient care component of the per
12 diem rate. Separate cost-based ceilings shall be calculated
13 for each patient care subcomponent. The direct care
14 subcomponent of the per diem rate shall be limited by the
15 cost-based class ceiling, and the indirect care subcomponent
16 shall be limited by the lower of the cost-based class ceiling,
17 by the target rate class ceiling, or by the individual
18 provider target. The agency shall adjust the patient care
19 component effective January 1, 2002. The cost to adjust the
20 direct care subcomponent shall be net of the total funds
21 previously allocated for the case mix add-on. The agency shall
22 make the required changes to the nursing home cost reporting
23 forms to implement this requirement effective January 1, 2002.
24 3. The direct care subcomponent shall include salaries
25 and benefits of direct care staff providing nursing services
26 including registered nurses, licensed practical nurses, and
27 certified nursing assistants who deliver care directly to
28 residents in the nursing home facility. This excludes nursing
29 administration, MDS, and care plan coordinators, staff
30 development, and staffing coordinator.
31
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1 4. All other patient care costs shall be included in
2 the indirect care cost subcomponent of the patient care per
3 diem rate. There shall be no costs directly or indirectly
4 allocated to the direct care subcomponent from a home office
5 or management company.
6 5. On July 1 of each year, the agency shall report to
7 the Legislature direct and indirect care costs, including
8 average direct and indirect care costs per resident per
9 facility and direct care and indirect care salaries and
10 benefits per category of staff member per facility.
11 6. Under the plan, interim rate adjustments shall not
12 be granted to reflect increases in the cost of general or
13 professional liability insurance for nursing homes unless the
14 following criteria are met: have at least a 65 percent
15 Medicaid utilization in the most recent cost report submitted
16 to the agency, and the increase in general or professional
17 liability costs to the facility for the most recent policy
18 period affects the total Medicaid per diem by at least 5
19 percent. This rate adjustment shall not result in the per diem
20 exceeding the class ceiling. This provision shall be
21 implemented to the extent existing appropriations are
22 available.
23
24 It is the intent of the Legislature that the reimbursement
25 plan achieve the goal of providing access to health care for
26 nursing home residents who require large amounts of care while
27 encouraging diversion services as an alternative to nursing
28 home care for residents who can be served within the
29 community. The agency shall base the establishment of any
30 maximum rate of payment, whether overall or component, on the
31 available moneys as provided for in the General Appropriations
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1 Act. The agency may base the maximum rate of payment on the
2 results of scientifically valid analysis and conclusions
3 derived from objective statistical data pertinent to the
4 particular maximum rate of payment.
5 (3) Subject to any limitations or directions provided
6 for in the General Appropriations Act, the following Medicaid
7 services and goods may be reimbursed on a fee-for-service
8 basis. For each allowable service or goods furnished in
9 accordance with Medicaid rules, policy manuals, handbooks, and
10 state and federal law, the payment shall be the amount billed
11 by the provider, the provider's usual and customary charge, or
12 the maximum allowable fee established by the agency, whichever
13 amount is less, with the exception of those services or goods
14 for which the agency makes payment using a methodology based
15 on capitation rates, average costs, or negotiated fees.
16 (a) Advanced registered nurse practitioner services.
17 (b) Birth center services.
18 (c) Chiropractic services.
19 (d) Community mental health services.
20 (e) Dental services, including oral and maxillofacial
21 surgery.
22 (f) Durable medical equipment.
23 (g) Hearing services.
24 (h) Occupational therapy for Medicaid recipients under
25 age 21.
26 (i) Optometric services.
27 (j) Orthodontic services.
28 (k) Personal care for Medicaid recipients under age
29 21.
30 (l) Physical therapy for Medicaid recipients under age
31 21.
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1 (m) Physician assistant services.
2 (n) Podiatric services.
3 (o) Portable X-ray services.
4 (p) Private-duty nursing for Medicaid recipients under
5 age 21.
6 (q) Registered nurse first assistant services.
7 (r) Respiratory therapy for Medicaid recipients under
8 age 21.
9 (s) Speech therapy for Medicaid recipients under age
10 21.
11 (t) Visual services.
12 (4) Subject to any limitations or directions provided
13 for in the General Appropriations Act, alternative health
14 plans, health maintenance organizations, and prepaid health
15 plans shall be reimbursed a fixed, prepaid amount negotiated,
16 or competitively bid pursuant to s. 287.057, by the agency and
17 prospectively paid to the provider monthly for each Medicaid
18 recipient enrolled. The amount may not exceed the average
19 amount the agency determines it would have paid, based on
20 claims experience, for recipients in the same or similar
21 category of eligibility. The agency shall calculate
22 capitation rates on a regional basis and, beginning September
23 1, 1995, shall include age-band differentials in such
24 calculations. Effective July 1, 2001, the cost of exempting
25 statutory teaching hospitals, specialty hospitals, and
26 community hospital education program hospitals from
27 reimbursement ceilings and the cost of special Medicaid
28 payments shall not be included in premiums paid to health
29 maintenance organizations or prepaid health care plans. Each
30 rate semester, the agency shall calculate and publish a
31 Medicaid hospital rate schedule that does not reflect either
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1 special Medicaid payments or the elimination of rate
2 reimbursement ceilings, to be used by hospitals and Medicaid
3 health maintenance organizations, in order to determine the
4 Medicaid rate referred to in ss. 409.912(16), 409.9128(5), and
5 641.513(6).
6 (5) An ambulatory surgical center shall be reimbursed
7 the lesser of the amount billed by the provider or the
8 Medicare-established allowable amount for the facility.
9 (6) A provider of early and periodic screening,
10 diagnosis, and treatment services to Medicaid recipients who
11 are children under age 21 shall be reimbursed using an
12 all-inclusive rate stipulated in a fee schedule established by
13 the agency. A provider of the visual, dental, and hearing
14 components of such services shall be reimbursed the lesser of
15 the amount billed by the provider or the Medicaid maximum
16 allowable fee established by the agency.
17 (7) A provider of family planning services shall be
18 reimbursed the lesser of the amount billed by the provider or
19 an all-inclusive amount per type of visit for physicians and
20 advanced registered nurse practitioners, as established by the
21 agency in a fee schedule.
22 (8) A provider of home-based or community-based
23 services rendered pursuant to a federally approved waiver
24 shall be reimbursed based on an established or negotiated rate
25 for each service. These rates shall be established according
26 to an analysis of the expenditure history and prospective
27 budget developed by each contract provider participating in
28 the waiver program, or under any other methodology adopted by
29 the agency and approved by the Federal Government in
30 accordance with the waiver. Effective July 1, 1996, privately
31 owned and operated community-based residential facilities
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1 which meet agency requirements and which formerly received
2 Medicaid reimbursement for the optional intermediate care
3 facility for the mentally retarded service may participate in
4 the developmental services waiver as part of a
5 home-and-community-based continuum of care for Medicaid
6 recipients who receive waiver services.
7 (9) A provider of home health care services or of
8 medical supplies and appliances shall be reimbursed on the
9 basis of competitive bidding or for the lesser of the amount
10 billed by the provider or the agency's established maximum
11 allowable amount, except that, in the case of the rental of
12 durable medical equipment, the total rental payments may not
13 exceed the purchase price of the equipment over its expected
14 useful life or the agency's established maximum allowable
15 amount, whichever amount is less.
16 (10) A hospice shall be reimbursed through a
17 prospective system for each Medicaid hospice patient at
18 Medicaid rates using the methodology established for hospice
19 reimbursement pursuant to Title XVIII of the federal Social
20 Security Act.
21 (11) A provider of independent laboratory services
22 shall be reimbursed on the basis of competitive bidding or for
23 the least of the amount billed by the provider, the provider's
24 usual and customary charge, or the Medicaid maximum allowable
25 fee established by the agency.
26 (12)(a) A physician shall be reimbursed the lesser of
27 the amount billed by the provider or the Medicaid maximum
28 allowable fee established by the agency.
29 (b) The agency shall adopt a fee schedule, subject to
30 any limitations or directions provided for in the General
31 Appropriations Act, based on a resource-based relative value
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1 scale for pricing Medicaid physician services. Under this fee
2 schedule, physicians shall be paid a dollar amount for each
3 service based on the average resources required to provide the
4 service, including, but not limited to, estimates of average
5 physician time and effort, practice expense, and the costs of
6 professional liability insurance. The fee schedule shall
7 provide increased reimbursement for preventive and primary
8 care services and lowered reimbursement for specialty services
9 by using at least two conversion factors, one for cognitive
10 services and another for procedural services. The fee
11 schedule shall not increase total Medicaid physician
12 expenditures unless moneys are available, and shall be phased
13 in over a 2-year period beginning on July 1, 1994. The Agency
14 for Health Care Administration shall seek the advice of a
15 16-member advisory panel in formulating and adopting the fee
16 schedule. The panel shall consist of Medicaid physicians
17 licensed under chapters 458 and 459 and shall be composed of
18 50 percent primary care physicians and 50 percent specialty
19 care physicians.
20 (c) Notwithstanding paragraph (b), reimbursement fees
21 to physicians for providing total obstetrical services to
22 Medicaid recipients, which include prenatal, delivery, and
23 postpartum care, shall be at least $1,500 per delivery for a
24 pregnant woman with low medical risk and at least $2,000 per
25 delivery for a pregnant woman with high medical risk. However,
26 reimbursement to physicians working in Regional Perinatal
27 Intensive Care Centers designated pursuant to chapter 383, for
28 services to certain pregnant Medicaid recipients with a high
29 medical risk, may be made according to obstetrical care and
30 neonatal care groupings and rates established by the agency.
31 Nurse midwives licensed under part I of chapter 464 or
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1 midwives licensed under chapter 467 shall be reimbursed at no
2 less than 80 percent of the low medical risk fee. The agency
3 shall by rule determine, for the purpose of this paragraph,
4 what constitutes a high or low medical risk pregnant woman and
5 shall not pay more based solely on the fact that a caesarean
6 section was performed, rather than a vaginal delivery. The
7 agency shall by rule determine a prorated payment for
8 obstetrical services in cases where only part of the total
9 prenatal, delivery, or postpartum care was performed. The
10 Department of Health shall adopt rules for appropriate
11 insurance coverage for midwives licensed under chapter 467.
12 Prior to the issuance and renewal of an active license, or
13 reactivation of an inactive license for midwives licensed
14 under chapter 467, such licensees shall submit proof of
15 coverage with each application.
16 (d) For the 2001-2002 fiscal year only and if
17 necessary to meet the requirements for grants and donations
18 for the special Medicaid payments authorized in the 2001-2002
19 General Appropriations Act, the agency may make special
20 Medicaid payments to qualified Medicaid providers designated
21 by the agency, notwithstanding any provision of this
22 subsection to the contrary, and may use intergovernmental
23 transfers from state entities to serve as the state share of
24 such payments.
25 (13) Medicare premiums for persons eligible for both
26 Medicare and Medicaid coverage shall be paid at the rates
27 established by Title XVIII of the Social Security Act. For
28 Medicare services rendered to Medicaid-eligible persons,
29 Medicaid shall pay Medicare deductibles and coinsurance as
30 follows:
31
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1 (a) Medicaid shall make no payment toward deductibles
2 and coinsurance for any service that is not covered by
3 Medicaid.
4 (b) Medicaid's financial obligation for deductibles
5 and coinsurance payments shall be based on Medicare allowable
6 fees, not on a provider's billed charges.
7 (c) Medicaid will pay no portion of Medicare
8 deductibles and coinsurance when payment that Medicare has
9 made for the service equals or exceeds what Medicaid would
10 have paid if it had been the sole payor. The combined payment
11 of Medicare and Medicaid shall not exceed the amount Medicaid
12 would have paid had it been the sole payor. The Legislature
13 finds that there has been confusion regarding the
14 reimbursement for services rendered to dually eligible
15 Medicare beneficiaries. Accordingly, the Legislature clarifies
16 that it has always been the intent of the Legislature before
17 and after 1991 that, in reimbursing in accordance with fees
18 established by Title XVIII for premiums, deductibles, and
19 coinsurance for Medicare services rendered by physicians to
20 Medicaid eligible persons, physicians be reimbursed at the
21 lesser of the amount billed by the physician or the Medicaid
22 maximum allowable fee established by the Agency for Health
23 Care Administration, as is permitted by federal law. It has
24 never been the intent of the Legislature with regard to such
25 services rendered by physicians that Medicaid be required to
26 provide any payment for deductibles, coinsurance, or
27 copayments for Medicare cost sharing, or any expenses incurred
28 relating thereto, in excess of the payment amount provided for
29 under the State Medicaid plan for such service. This payment
30 methodology is applicable even in those situations in which
31 the payment for Medicare cost sharing for a qualified Medicare
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1 beneficiary with respect to an item or service is reduced or
2 eliminated. This expression of the Legislature is in
3 clarification of existing law and shall apply to payment for,
4 and with respect to provider agreements with respect to, items
5 or services furnished on or after the effective date of this
6 act. This paragraph applies to payment by Medicaid for items
7 and services furnished before the effective date of this act
8 if such payment is the subject of a lawsuit that is based on
9 the provisions of this section, and that is pending as of, or
10 is initiated after, the effective date of this act.
11 (d) Notwithstanding paragraphs (a)-(c):
12 1. Medicaid payments for Nursing Home Medicare part A
13 coinsurance shall be the lesser of the Medicare coinsurance
14 amount or the Medicaid nursing home per diem rate.
15 2. Medicaid shall pay all deductibles and coinsurance
16 for Medicare-eligible recipients receiving freestanding end
17 stage renal dialysis center services.
18 3. Medicaid payments for general hospital inpatient
19 services shall be limited to the Medicare deductible per spell
20 of illness. Medicaid shall make no payment toward coinsurance
21 for Medicare general hospital inpatient services.
22 4. Medicaid shall pay all deductibles and coinsurance
23 for Medicare emergency transportation services provided by
24 ambulances licensed pursuant to chapter 401.
25 (14) A provider of prescribed drugs shall be
26 reimbursed the least of the amount billed by the provider, the
27 provider's usual and customary charge, or the Medicaid maximum
28 allowable fee established by the agency, plus a dispensing
29 fee. The agency is directed to implement a variable dispensing
30 fee for payments for prescribed medicines while ensuring
31 continued access for Medicaid recipients. The variable
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1 dispensing fee may be based upon, but not limited to, either
2 or both the volume of prescriptions dispensed by a specific
3 pharmacy provider, the volume of prescriptions dispensed to an
4 individual recipient, and dispensing of preferred-drug-list
5 products. The agency shall increase the pharmacy dispensing
6 fee authorized by statute and in the annual General
7 Appropriations Act by $0.50 for the dispensing of a Medicaid
8 preferred-drug-list product and reduce the pharmacy dispensing
9 fee by $0.50 for the dispensing of a Medicaid product that is
10 not included on the preferred-drug list. The agency is
11 authorized to limit reimbursement for prescribed medicine in
12 order to comply with any limitations or directions provided
13 for in the General Appropriations Act, which may include
14 implementing a prospective or concurrent utilization review
15 program.
16 (15) A provider of primary care case management
17 services rendered pursuant to a federally approved waiver
18 shall be reimbursed by payment of a fixed, prepaid monthly sum
19 for each Medicaid recipient enrolled with the provider.
20 (16) A provider of rural health clinic services and
21 federally qualified health center services shall be reimbursed
22 a rate per visit based on total reasonable costs of the
23 clinic, as determined by the agency in accordance with federal
24 regulations.
25 (17) A provider of targeted case management services
26 shall be reimbursed pursuant to an established fee, except
27 where the Federal Government requires a public provider be
28 reimbursed on the basis of average actual costs.
29 (18) Unless otherwise provided for in the General
30 Appropriations Act, a provider of transportation services
31 shall be reimbursed the lesser of the amount billed by the
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1 provider or the Medicaid maximum allowable fee established by
2 the agency, except when the agency has entered into a direct
3 contract with the provider, or with a community transportation
4 coordinator, for the provision of an all-inclusive service, or
5 when services are provided pursuant to an agreement negotiated
6 between the agency and the provider. The agency, as provided
7 for in s. 427.0135, shall purchase transportation services
8 through the community coordinated transportation system, if
9 available, unless the agency determines a more cost-effective
10 method for Medicaid clients. Nothing in this subsection shall
11 be construed to limit or preclude the agency from contracting
12 for services using a prepaid capitation rate or from
13 establishing maximum fee schedules, individualized
14 reimbursement policies by provider type, negotiated fees,
15 prior authorization, competitive bidding, increased use of
16 mass transit, or any other mechanism that the agency considers
17 efficient and effective for the purchase of services on behalf
18 of Medicaid clients, including implementing a transportation
19 eligibility process. The agency shall not be required to
20 contract with any community transportation coordinator or
21 transportation operator that has been determined by the
22 agency, the Department of Legal Affairs Medicaid Fraud Control
23 Unit, or any other state or federal agency to have engaged in
24 any abusive or fraudulent billing activities. The agency is
25 authorized to competitively procure transportation services or
26 make other changes necessary to secure approval of federal
27 waivers needed to permit federal financing of Medicaid
28 transportation services at the service matching rate rather
29 than the administrative matching rate.
30 (19) County health department services may be
31 reimbursed a rate per visit based on total reasonable costs of
32
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1 the clinic, as determined by the agency in accordance with
2 federal regulations under the authority of 42 C.F.R. s.
3 431.615.
4 (20) A renal dialysis facility that provides dialysis
5 services under s. 409.906(9) must be reimbursed the lesser of
6 the amount billed by the provider, the provider's usual and
7 customary charge, or the maximum allowable fee established by
8 the agency, whichever amount is less.
9 (21) The agency shall reimburse school districts which
10 certify the state match pursuant to ss. 236.0812 and 409.9071
11 for the federal portion of the school district's allowable
12 costs to deliver the services, based on the reimbursement
13 schedule. The school district shall determine the costs for
14 delivering services as authorized in ss. 236.0812 and 409.9071
15 for which the state match will be certified. Reimbursement of
16 school-based providers is contingent on such providers being
17 enrolled as Medicaid providers and meeting the qualifications
18 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
19 the federal Health Care Financing Administration. Speech
20 therapy providers who are certified through the Department of
21 Education pursuant to rule 6A-4.0176, Florida Administrative
22 Code, are eligible for reimbursement for services that are
23 provided on school premises. Any employee of the school
24 district who has been fingerprinted and has received a
25 criminal background check in accordance with Department of
26 Education rules and guidelines shall be exempt from any agency
27 requirements relating to criminal background checks.
28 (22) The agency shall request and implement Medicaid
29 waivers from the federal Health Care Financing Administration
30 to advance and treat a portion of the Medicaid nursing home
31 per diem as capital for creating and operating a
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1 risk-retention group for self-insurance purposes, consistent
2 with federal and state laws and rules.
3 Section 12. Paragraph (b) of subsection (7) of section
4 409.910, Florida Statutes, is amended to read:
5 409.910 Responsibility for payments on behalf of
6 Medicaid-eligible persons when other parties are liable.--
7 (7) The agency shall recover the full amount of all
8 medical assistance provided by Medicaid on behalf of the
9 recipient to the full extent of third-party benefits.
10 (b) Upon receipt of any recovery or other collection
11 pursuant to this section, s. 409.913, or s. 409.920, the
12 agency shall distribute the amount collected as follows:
13 1. To itself and to any county that has responsibility
14 for certain items of care and service as mandated in s.
15 409.915, amounts an amount equal to a pro rata distribution of
16 the county's contribution and the state's state respective
17 Medicaid expenditures for the recipient plus any incentive
18 payment made in accordance with paragraph (14)(a). However, if
19 a county has been billed for its participation but has not
20 paid the amount due, the agency shall offset that amount and
21 notify the county of the amount of the offset. If the county
22 has divided its financial responsibility between the county
23 and a special taxing district or authority as contemplated in
24 s. 409.915(6), the county must proportionately divide any
25 refund or offset in accordance with the proration that it has
26 established.
27 2. To the Federal Government, the federal share of the
28 state Medicaid expenditures minus any incentive payment made
29 in accordance with paragraph (14)(a) and federal law, and
30 minus any other amount permitted by federal law to be
31 deducted.
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1 3. To the recipient, after deducting any known amounts
2 owed to the agency for any related medical assistance or to
3 health care providers, any remaining amount. This amount shall
4 be treated as income or resources in determining eligibility
5 for Medicaid.
6
7 The provisions of this subsection do not apply to any proceeds
8 received by the state, or any agency thereof, pursuant to a
9 final order, judgment, or settlement agreement, in any matter
10 in which the state asserts claims brought on its own behalf,
11 and not as a subrogee of a recipient, or under other theories
12 of liability. The provisions of this subsection do not apply
13 to any proceeds received by the state, or an agency thereof,
14 pursuant to a final order, judgment, or settlement agreement,
15 in any matter in which the state asserted both claims as a
16 subrogee and additional claims, except as to those sums
17 specifically identified in the final order, judgment, or
18 settlement agreement as reimbursements to the recipient as
19 expenditures for the named recipient on the subrogation claim.
20 Section 13. Subsection (7) of section 409.9116,
21 Florida Statutes, is amended to read:
22 409.9116 Disproportionate share/financial assistance
23 program for rural hospitals.--In addition to the payments made
24 under s. 409.911, the Agency for Health Care Administration
25 shall administer a federally matched disproportionate share
26 program and a state-funded financial assistance program for
27 statutory rural hospitals. The agency shall make
28 disproportionate share payments to statutory rural hospitals
29 that qualify for such payments and financial assistance
30 payments to statutory rural hospitals that do not qualify for
31 disproportionate share payments. The disproportionate share
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1 program payments shall be limited by and conform with federal
2 requirements. Funds shall be distributed quarterly in each
3 fiscal year for which an appropriation is made.
4 Notwithstanding the provisions of s. 409.915, counties are
5 exempt from contributing toward the cost of this special
6 reimbursement for hospitals serving a disproportionate share
7 of low-income patients.
8 (7) This section applies only to hospitals that were
9 defined as statutory rural hospitals, or their
10 successor-in-interest hospital, prior to July 1, 1999 1998.
11 Any additional hospital that is defined as a statutory rural
12 hospital, or its successor-in-interest hospital, on or after
13 July 1, 1999 1998, is not eligible for programs under this
14 section unless additional funds are appropriated each fiscal
15 year specifically to the rural hospital disproportionate share
16 and financial assistance programs in an amount necessary to
17 prevent any hospital, or its successor-in-interest hospital,
18 eligible for the programs prior to July 1, 1999 1998, from
19 incurring a reduction in payments because of the eligibility
20 of an additional hospital to participate in the programs. A
21 hospital, or its successor-in-interest hospital, which
22 received funds pursuant to this section before July 1, 1999
23 1998, and which qualifies under s. 395.602(2)(e), shall be
24 included in the programs under this section and is not
25 required to seek additional appropriations under this
26 subsection.
27 Section 14. Paragraph (b) of subsection (3) and
28 paragraph (b) of subsection (13) of section 409.912, Florida
29 Statutes, are amended to read:
30 409.912 Cost-effective purchasing of health care.--The
31 agency shall purchase goods and services for Medicaid
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1 recipients in the most cost-effective manner consistent with
2 the delivery of quality medical care. The agency shall
3 maximize the use of prepaid per capita and prepaid aggregate
4 fixed-sum basis services when appropriate and other
5 alternative service delivery and reimbursement methodologies,
6 including competitive bidding pursuant to s. 287.057, designed
7 to facilitate the cost-effective purchase of a case-managed
8 continuum of care. The agency shall also require providers to
9 minimize the exposure of recipients to the need for acute
10 inpatient, custodial, and other institutional care and the
11 inappropriate or unnecessary use of high-cost services. The
12 agency may establish prior authorization requirements for
13 certain populations of Medicaid beneficiaries, certain drug
14 classes, or particular drugs to prevent fraud, abuse, overuse,
15 and possible dangerous drug interactions. The Pharmaceutical
16 and Therapeutics Committee shall make recommendations to the
17 agency on drugs for which prior authorization is required. The
18 agency shall inform the Pharmaceutical and Therapeutics
19 Committee of its decisions regarding drugs subject to prior
20 authorization.
21 (3) The agency may contract with:
22 (b) An entity that is providing comprehensive
23 behavioral health care services to certain Medicaid recipients
24 through a capitated, prepaid arrangement pursuant to the
25 federal waiver provided for by s. 409.905(5). Such an entity
26 must be licensed under chapter 624, chapter 636, or chapter
27 641 and must possess the clinical systems and operational
28 competence to manage risk and provide comprehensive behavioral
29 health care to Medicaid recipients. As used in this paragraph,
30 the term "comprehensive behavioral health care services" means
31 covered mental health and substance abuse treatment services
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1 that are available to Medicaid recipients. The secretary of
2 the Department of Children and Family Services shall approve
3 provisions of procurements related to children in the
4 department's care or custody prior to enrolling such children
5 in a prepaid behavioral health plan. Any contract awarded
6 under this paragraph must be competitively procured. In
7 developing the behavioral health care prepaid plan procurement
8 document, the agency shall ensure that the procurement
9 document requires the contractor to develop and implement a
10 plan to ensure compliance with s. 394.4574 related to services
11 provided to residents of licensed assisted living facilities
12 that hold a limited mental health license. The agency must
13 ensure that Medicaid recipients have available the choice of
14 at least two managed care plans for their behavioral health
15 care services. To ensure unimpaired access to behavioral
16 health care services by Medicaid recipients, all contracts
17 issued pursuant to this paragraph shall require 80 percent of
18 the capitation paid to the managed care plan, including health
19 maintenance organizations, to be expended for the provision of
20 behavioral health care services. In the event the managed care
21 plan expends less than 80 percent of the capitation paid
22 pursuant to this paragraph for the provision of behavioral
23 health care services, the difference shall be returned to the
24 agency. The agency shall provide the managed care plan with a
25 certification letter indicating the amount of capitation paid
26 during each calendar year for the provision of behavioral
27 health care services pursuant to this section. The agency may
28 reimburse for substance-abuse-treatment services on a
29 fee-for-service basis until the agency finds that adequate
30 funds are available for capitated, prepaid arrangements.
31
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1 1. By January 1, 2001, the agency shall modify the
2 contracts with the entities providing comprehensive inpatient
3 and outpatient mental health care services to Medicaid
4 recipients in Hillsborough, Highlands, Hardee, Manatee, and
5 Polk Counties, to include substance-abuse-treatment services.
6 2. By December 31, 2001, the agency shall contract
7 with entities providing comprehensive behavioral health care
8 services to Medicaid recipients through capitated, prepaid
9 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
10 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
11 and Walton Counties. The agency may contract with entities
12 providing comprehensive behavioral health care services to
13 Medicaid recipients through capitated, prepaid arrangements in
14 Alachua County. The agency may determine if Sarasota County
15 shall be included as a separate catchment area or included in
16 any other agency geographic area.
17 3. Children residing in a Department of Juvenile
18 Justice residential program approved as a Medicaid behavioral
19 health overlay services provider shall not be included in a
20 behavioral health care prepaid health plan pursuant to this
21 paragraph.
22 4. In converting to a prepaid system of delivery, the
23 agency shall in its procurement document require an entity
24 providing comprehensive behavioral health care services to
25 prevent the displacement of indigent care patients by
26 enrollees in the Medicaid prepaid health plan providing
27 behavioral health care services from facilities receiving
28 state funding to provide indigent behavioral health care, to
29 facilities licensed under chapter 395 which do not receive
30 state funding for indigent behavioral health care, or
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1 reimburse the unsubsidized facility for the cost of behavioral
2 health care provided to the displaced indigent care patient.
3 5. Traditional community mental health providers under
4 contract with the Department of Children and Family Services
5 pursuant to part IV of chapter 394 and inpatient mental health
6 providers licensed pursuant to chapter 395 must be offered an
7 opportunity to accept or decline a contract to participate in
8 any provider network for prepaid behavioral health services.
9 (13)
10 (b) The responsibility of the agency under this
11 subsection shall include the development of capabilities to
12 identify actual and optimal practice patterns; patient and
13 provider educational initiatives; methods for determining
14 patient compliance with prescribed treatments; fraud, waste,
15 and abuse prevention and detection programs; and beneficiary
16 case management programs.
17 1. The practice pattern identification program shall
18 evaluate practitioner prescribing patterns based on national
19 and regional practice guidelines, comparing practitioners to
20 their peer groups. The agency and its Drug Utilization Review
21 Board shall consult with a panel of practicing health care
22 professionals consisting of the following: the Speaker of the
23 House of Representatives and the President of the Senate shall
24 each appoint three physicians licensed under chapter 458 or
25 chapter 459; and the Governor shall appoint two pharmacists
26 licensed under chapter 465 and one dentist licensed under
27 chapter 466 who is an oral surgeon. Terms of the panel members
28 shall expire at the discretion of the appointing official. The
29 panel shall begin its work by August 1, 1999, regardless of
30 the number of appointments made by that date. The advisory
31 panel shall be responsible for evaluating treatment guidelines
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1 and recommending ways to incorporate their use in the practice
2 pattern identification program. Practitioners who are
3 prescribing inappropriately or inefficiently, as determined by
4 the agency, may have their prescribing of certain drugs
5 subject to prior authorization.
6 2. The agency shall also develop educational
7 interventions designed to promote the proper use of
8 medications by providers and beneficiaries.
9 3. The agency shall implement a pharmacy fraud, waste,
10 and abuse initiative that may include a surety bond or letter
11 of credit requirement for participating pharmacies, enhanced
12 provider auditing practices, the use of additional fraud and
13 abuse software, recipient management programs for
14 beneficiaries inappropriately using their benefits, and other
15 steps that will eliminate provider and recipient fraud, waste,
16 and abuse. The initiative shall address enforcement efforts to
17 reduce the number and use of counterfeit prescriptions.
18 4. By September 30, 2002, the agency shall contract
19 with an entity in the state to implement a wireless handheld
20 clinical pharmacology drug information database for
21 high-prescribing practitioners, as determined by the agency.
22 The initiative shall be designed to enhance the agency's
23 efforts to reduce fraud, abuse, and errors in the prescription
24 drug benefit program and to otherwise further the intent of
25 this paragraph.
26 5.4. The agency may apply for any federal waivers
27 needed to implement this paragraph.
28 Section 15. Paragraph (f) of subsection (2) of section
29 409.9122, Florida Statutes, as amended by section 11 of
30 chapter 2001-377, Laws of Florida, is amended to read:
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1 409.9122 Mandatory Medicaid managed care enrollment;
2 programs and procedures.--
3 (2)
4 (f) When a Medicaid recipient does not choose a
5 managed care plan or MediPass provider, the agency shall
6 assign the Medicaid recipient to a managed care plan or
7 MediPass provider. Medicaid recipients who are subject to
8 mandatory assignment but who fail to make a choice shall be
9 assigned to managed care plans or provider service networks
10 until a proportional an equal enrollment of 45 50 percent in
11 MediPass and 55 50 percent in managed care plans is achieved.
12 Once the 45/55 proportional equal enrollment is achieved, the
13 assignments shall be divided in order to maintain an equal
14 enrollment in MediPass and managed care plans. Thereafter,
15 assignment of Medicaid recipients who fail to make a choice
16 shall be based proportionally on the preferences of recipients
17 who have made a choice in the previous period. Such
18 proportions shall be revised at least quarterly to reflect an
19 update of the preferences of Medicaid recipients. The agency
20 shall also disproportionately assign Medicaid-eligible
21 children in families who are required to but have failed to
22 make a choice of managed care plan or MediPass for their child
23 and who are to be assigned to the MediPass program to
24 children's networks as described in s. 409.912(3)(g) and where
25 available. The disproportionate assignment of children to
26 children's networks shall be made until the agency has
27 determined that the children's networks have sufficient
28 numbers to be economically operated. For purposes of this
29 paragraph, when referring to assignment, the term "managed
30 care plans" includes exclusive provider organizations,
31 provider service networks, minority physician networks, and
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1 pediatric emergency department diversion programs authorized
2 by this chapter or the General Appropriations Act. When making
3 assignments, the agency shall take into account the following
4 criteria:
5 1. A managed care plan has sufficient network capacity
6 to meet the need of members.
7 2. The managed care plan or MediPass has previously
8 enrolled the recipient as a member, or one of the managed care
9 plan's primary care providers or MediPass providers has
10 previously provided health care to the recipient.
11 3. The agency has knowledge that the member has
12 previously expressed a preference for a particular managed
13 care plan or MediPass provider as indicated by Medicaid
14 fee-for-service claims data, but has failed to make a choice.
15 4. The managed care plan's or MediPass primary care
16 providers are geographically accessible to the recipient's
17 residence.
18 Section 16. Section 409.913, Florida Statutes, as
19 amended by section 12 of chapter 2001-377, Laws of Florida, is
20 amended to read:
21 409.913 Oversight of the integrity of the Medicaid
22 program.--The agency shall operate a program to oversee the
23 activities of Florida Medicaid recipients, and providers and
24 their representatives, to ensure that fraudulent and abusive
25 behavior and neglect of recipients occur to the minimum extent
26 possible, and to recover overpayments and impose sanctions as
27 appropriate. Beginning January 1, 2003, and each year
28 thereafter, the agency and the Medicaid Fraud Control Unit of
29 the Department of Legal Affairs shall submit a joint report to
30 the Legislature documenting the effectiveness of the state's
31 efforts to control Medicaid fraud and abuse and to recover
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1 Medicaid overpayments during the previous fiscal year. The
2 report must describe the number of cases opened and
3 investigated each year; the sources of the cases opened; the
4 disposition of the cases closed each year; the amount of
5 overpayments alleged in preliminary and final audit letters;
6 the number and amount of fines or penalties imposed; any
7 reductions in overpayment amounts negotiated in settlement
8 agreements or by other means; the amount of final agency
9 determinations of overpayments; the amount deducted from
10 federal claiming as a result of overpayments; the amount of
11 overpayments recovered each year; the amount of cost of
12 investigation recovered each year; the average length of time
13 to collect from the time the case was opened until the
14 overpayment is paid in full; the amount determined as
15 uncollectible and the portion of the uncollectible amount
16 subsequently reclaimed from the Federal Government; the number
17 of providers, by type, that are terminated from participation
18 in the Medicaid program as a result of fraud and abuse; and
19 all costs associated with discovering and prosecuting cases of
20 Medicaid overpayments and making recoveries in such cases. The
21 report must also document actions taken to prevent
22 overpayments and the number of providers prevented from
23 enrolling in or reenrolling in the Medicaid program as a
24 result of documented Medicaid fraud and abuse and must
25 recommend changes necessary to prevent or recover
26 overpayments. For the 2001-2002 fiscal year, the agency shall
27 prepare a report that contains as much of this information as
28 is available to it.
29 (1) For the purposes of this section, the term:
30 (a) "Abuse" means:
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1 1. Provider practices that are inconsistent with
2 generally accepted business or medical practices and that
3 result in an unnecessary cost to the Medicaid program or in
4 reimbursement for goods or services that are not medically
5 necessary or that fail to meet professionally recognized
6 standards for health care.
7 2. Recipient practices that result in unnecessary cost
8 to the Medicaid program.
9 (b) "Complaint" means an allegation that fraud, abuse,
10 or an overpayment has occurred.
11 (c)(b) "Fraud" means an intentional deception or
12 misrepresentation made by a person with the knowledge that the
13 deception results in unauthorized benefit to herself or
14 himself or another person. The term includes any act that
15 constitutes fraud under applicable federal or state law.
16 (d)(c) "Medical necessity" or "medically necessary"
17 means any goods or services necessary to palliate the effects
18 of a terminal condition, or to prevent, diagnose, correct,
19 cure, alleviate, or preclude deterioration of a condition that
20 threatens life, causes pain or suffering, or results in
21 illness or infirmity, which goods or services are provided in
22 accordance with generally accepted standards of medical
23 practice. For purposes of determining Medicaid reimbursement,
24 the agency is the final arbiter of medical necessity.
25 Determinations of medical necessity must be made by a licensed
26 physician employed by or under contract with the agency and
27 must be based upon information available at the time the goods
28 or services are provided.
29 (e)(d) "Overpayment" includes any amount that is not
30 authorized to be paid by the Medicaid program whether paid as
31
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1 a result of inaccurate or improper cost reporting, improper
2 claiming, unacceptable practices, fraud, abuse, or mistake.
3 (f)(e) "Person" means any natural person, corporation,
4 partnership, association, clinic, group, or other entity,
5 whether or not such person is enrolled in the Medicaid program
6 or is a provider of health care.
7 (2) The agency shall conduct, or cause to be conducted
8 by contract or otherwise, reviews, investigations, analyses,
9 audits, or any combination thereof, to determine possible
10 fraud, abuse, overpayment, or recipient neglect in the
11 Medicaid program and shall report the findings of any
12 overpayments in audit reports as appropriate.
13 (3) The agency may conduct, or may contract for,
14 prepayment review of provider claims to ensure cost-effective
15 purchasing, billing, and provision of care to Medicaid
16 recipients. Such prepayment reviews may be conducted as
17 determined appropriate by the agency, without any suspicion or
18 allegation of fraud, abuse, or neglect.
19 (4) Any suspected criminal violation identified by the
20 agency must be referred to the Medicaid Fraud Control Unit of
21 the Office of the Attorney General for investigation. The
22 agency and the Attorney General shall enter into a memorandum
23 of understanding, which must include, but need not be limited
24 to, a protocol for regularly sharing information and
25 coordinating casework. The protocol must establish a
26 procedure for the referral by the agency of cases involving
27 suspected Medicaid fraud to the Medicaid Fraud Control Unit
28 for investigation, and the return to the agency of those cases
29 where investigation determines that administrative action by
30 the agency is appropriate. Offices of the Medicaid program
31 integrity program and the Medicaid Fraud Control Unit of the
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1 Department of Legal Affairs shall, to the extent possible, be
2 colocated. The agency and the Department of Legal Affairs
3 shall periodically conduct joint training and other joint
4 activities designed to increase communication and coordination
5 in recovering overpayments.
6 (5) A Medicaid provider is subject to having goods and
7 services that are paid for by the Medicaid program reviewed by
8 an appropriate peer-review organization designated by the
9 agency. The written findings of the applicable peer-review
10 organization are admissible in any court or administrative
11 proceeding as evidence of medical necessity or the lack
12 thereof.
13 (6) Any notice required to be given to a provider
14 under this section is presumed to be sufficient notice if sent
15 to the address last shown on the provider enrollment file. It
16 is the responsibility of the provider to furnish and keep the
17 agency informed of the provider's current address. United
18 States Postal Service proof of mailing or certified or
19 registered mailing of such notice to the provider at the
20 address shown on the provider enrollment file constitutes
21 sufficient proof of notice. Any notice required to be given to
22 the agency by this section must be sent to the agency at an
23 address designated by rule.
24 (7) When presenting a claim for payment under the
25 Medicaid program, a provider has an affirmative duty to
26 supervise the provision of, and be responsible for, goods and
27 services claimed to have been provided, to supervise and be
28 responsible for preparation and submission of the claim, and
29 to present a claim that is true and accurate and that is for
30 goods and services that:
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1 (a) Have actually been furnished to the recipient by
2 the provider prior to submitting the claim.
3 (b) Are Medicaid-covered goods or services that are
4 medically necessary.
5 (c) Are of a quality comparable to those furnished to
6 the general public by the provider's peers.
7 (d) Have not been billed in whole or in part to a
8 recipient or a recipient's responsible party, except for such
9 copayments, coinsurance, or deductibles as are authorized by
10 the agency.
11 (e) Are provided in accord with applicable provisions
12 of all Medicaid rules, regulations, handbooks, and policies
13 and in accordance with federal, state, and local law.
14 (f) Are documented by records made at the time the
15 goods or services were provided, demonstrating the medical
16 necessity for the goods or services rendered. Medicaid goods
17 or services are excessive or not medically necessary unless
18 both the medical basis and the specific need for them are
19 fully and properly documented in the recipient's medical
20 record.
21 (8) A Medicaid provider shall retain medical,
22 professional, financial, and business records pertaining to
23 services and goods furnished to a Medicaid recipient and
24 billed to Medicaid for a period of 5 years after the date of
25 furnishing such services or goods. The agency may investigate,
26 review, or analyze such records, which must be made available
27 during normal business hours. However, 24-hour notice must be
28 provided if patient treatment would be disrupted. The provider
29 is responsible for furnishing to the agency, and keeping the
30 agency informed of the location of, the provider's
31 Medicaid-related records. The authority of the agency to
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1 obtain Medicaid-related records from a provider is neither
2 curtailed nor limited during a period of litigation between
3 the agency and the provider.
4 (9) Payments for the services of billing agents or
5 persons participating in the preparation of a Medicaid claim
6 shall not be based on amounts for which they bill nor based on
7 the amount a provider receives from the Medicaid program.
8 (10) The agency may require repayment for
9 inappropriate, medically unnecessary, or excessive goods or
10 services from the person furnishing them, the person under
11 whose supervision they were furnished, or the person causing
12 them to be furnished.
13 (11) The complaint and all information obtained
14 pursuant to an investigation of a Medicaid provider, or the
15 authorized representative or agent of a provider, relating to
16 an allegation of fraud, abuse, or neglect are confidential and
17 exempt from the provisions of s. 119.07(1):
18 (a) Until the agency takes final agency action with
19 respect to the provider and requires repayment of any
20 overpayment, or imposes an administrative sanction;
21 (b) Until the Attorney General refers the case for
22 criminal prosecution;
23 (c) Until 10 days after the complaint is determined
24 without merit; or
25 (d) At all times if the complaint or information is
26 otherwise protected by law.
27 (12) The agency may terminate participation of a
28 Medicaid provider in the Medicaid program and may seek civil
29 remedies or impose other administrative sanctions against a
30 Medicaid provider, if the provider has been:
31
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1 (a) Convicted of a criminal offense related to the
2 delivery of any health care goods or services, including the
3 performance of management or administrative functions relating
4 to the delivery of health care goods or services;
5 (b) Convicted of a criminal offense under federal law
6 or the law of any state relating to the practice of the
7 provider's profession; or
8 (c) Found by a court of competent jurisdiction to have
9 neglected or physically abused a patient in connection with
10 the delivery of health care goods or services.
11 (13) If the provider has been suspended or terminated
12 from participation in the Medicaid program or the Medicare
13 program by the Federal Government or any state, the agency
14 must immediately suspend or terminate, as appropriate, the
15 provider's participation in the Florida Medicaid program for a
16 period no less than that imposed by the Federal Government or
17 any other state, and may not enroll such provider in the
18 Florida Medicaid program while such foreign suspension or
19 termination remains in effect. This sanction is in addition
20 to all other remedies provided by law.
21 (14) The agency may seek any remedy provided by law,
22 including, but not limited to, the remedies provided in
23 subsections (12) and (15) and s. 812.035, if:
24 (a) The provider's license has not been renewed, or
25 has been revoked, suspended, or terminated, for cause, by the
26 licensing agency of any state;
27 (b) The provider has failed to make available or has
28 refused access to Medicaid-related records to an auditor,
29 investigator, or other authorized employee or agent of the
30 agency, the Attorney General, a state attorney, or the Federal
31 Government;
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1 (c) The provider has not furnished or has failed to
2 make available such Medicaid-related records as the agency has
3 found necessary to determine whether Medicaid payments are or
4 were due and the amounts thereof;
5 (d) The provider has failed to maintain medical
6 records made at the time of service, or prior to service if
7 prior authorization is required, demonstrating the necessity
8 and appropriateness of the goods or services rendered;
9 (e) The provider is not in compliance with provisions
10 of Medicaid provider publications that have been adopted by
11 reference as rules in the Florida Administrative Code; with
12 provisions of state or federal laws, rules, or regulations;
13 with provisions of the provider agreement between the agency
14 and the provider; or with certifications found on claim forms
15 or on transmittal forms for electronically submitted claims
16 that are submitted by the provider or authorized
17 representative, as such provisions apply to the Medicaid
18 program;
19 (f) The provider or person who ordered or prescribed
20 the care, services, or supplies has furnished, or ordered the
21 furnishing of, goods or services to a recipient which are
22 inappropriate, unnecessary, excessive, or harmful to the
23 recipient or are of inferior quality;
24 (g) The provider has demonstrated a pattern of failure
25 to provide goods or services that are medically necessary;
26 (h) The provider or an authorized representative of
27 the provider, or a person who ordered or prescribed the goods
28 or services, has submitted or caused to be submitted false or
29 a pattern of erroneous Medicaid claims that have resulted in
30 overpayments to a provider or that exceed those to which the
31 provider was entitled under the Medicaid program;
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1 (i) The provider or an authorized representative of
2 the provider, or a person who has ordered or prescribed the
3 goods or services, has submitted or caused to be submitted a
4 Medicaid provider enrollment application, a request for prior
5 authorization for Medicaid services, a drug exception request,
6 or a Medicaid cost report that contains materially false or
7 incorrect information;
8 (j) The provider or an authorized representative of
9 the provider has collected from or billed a recipient or a
10 recipient's responsible party improperly for amounts that
11 should not have been so collected or billed by reason of the
12 provider's billing the Medicaid program for the same service;
13 (k) The provider or an authorized representative of
14 the provider has included in a cost report costs that are not
15 allowable under a Florida Title XIX reimbursement plan, after
16 the provider or authorized representative had been advised in
17 an audit exit conference or audit report that the costs were
18 not allowable;
19 (l) The provider is charged by information or
20 indictment with fraudulent billing practices. The sanction
21 applied for this reason is limited to suspension of the
22 provider's participation in the Medicaid program for the
23 duration of the indictment unless the provider is found guilty
24 pursuant to the information or indictment;
25 (m) The provider or a person who has ordered, or
26 prescribed the goods or services is found liable for negligent
27 practice resulting in death or injury to the provider's
28 patient;
29 (n) The provider fails to demonstrate that it had
30 available during a specific audit or review period sufficient
31 quantities of goods, or sufficient time in the case of
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1 services, to support the provider's billings to the Medicaid
2 program;
3 (o) The provider has failed to comply with the notice
4 and reporting requirements of s. 409.907; or
5 (p) The agency has received reliable information of
6 patient abuse or neglect or of any act prohibited by s.
7 409.920;.
8 (q) The provider has failed to comply with an
9 agreed-upon repayment schedule; or
10 (r) The provider has failed to timely file such
11 Medicaid cost reports as the agency considers necessary to set
12 or adjust payment rates.
13 (15) The agency shall may impose any of the following
14 sanctions or disincentives on a provider or a person for any
15 of the acts described in subsection (14):
16 (a) Suspension for a specific period of time of not
17 more than 1 year.
18 (b) Termination for a specific period of time of from
19 more than 1 year to 20 years.
20 (c) Imposition of a fine of up to $5,000 for each
21 violation. Each day that an ongoing violation continues, such
22 as refusing to furnish Medicaid-related records or refusing
23 access to records, is considered, for the purposes of this
24 section, to be a separate violation. Each instance of
25 improper billing of a Medicaid recipient; each instance of
26 including an unallowable cost on a hospital or nursing home
27 Medicaid cost report after the provider or authorized
28 representative has been advised in an audit exit conference or
29 previous audit report of the cost unallowability; each
30 instance of furnishing a Medicaid recipient goods or
31 professional services that are inappropriate or of inferior
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1 quality as determined by competent peer judgment; each
2 instance of knowingly submitting a materially false or
3 erroneous Medicaid provider enrollment application, request
4 for prior authorization for Medicaid services, drug exception
5 request, or cost report; each instance of inappropriate
6 prescribing of drugs for a Medicaid recipient as determined by
7 competent peer judgment; and each false or erroneous Medicaid
8 claim leading to an overpayment to a provider is considered,
9 for the purposes of this section, to be a separate violation.
10 (d) Immediate suspension, if the agency has received
11 information of patient abuse or neglect or of any act
12 prohibited by s. 409.920. Upon suspension, the agency must
13 issue an immediate final order under s. 120.569(2)(n).
14 (e) A fine, not to exceed $10,000, for a violation of
15 paragraph (14)(i).
16 (f) Imposition of liens against provider assets,
17 including, but not limited to, financial assets and real
18 property, not to exceed the amount of fines or recoveries
19 sought, upon entry of an order determining that such moneys
20 are due or recoverable.
21 (g) Prepayment reviews of claims for a specified
22 period of time.
23 (h) Comprehensive followup reviews of providers every
24 6 months to ensure that they are billing Medicaid correctly.
25 (i) Corrective action plans that would remain in
26 effect for providers for up to 3 years and that would be
27 monitored by the agency every 6 months while in effect.
28 (j)(g) Other remedies as permitted by law to effect
29 the recovery of a fine or overpayment.
30
31
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1 The Secretary of Health Care Administration may make a
2 determination that imposition of a sanction or disincentive is
3 not in the best interest of the Medicaid program, in which
4 case a sanction or disincentive shall not be imposed.
5 (16) In determining the appropriate administrative
6 sanction to be applied, or the duration of any suspension or
7 termination, the agency shall consider:
8 (a) The seriousness and extent of the violation or
9 violations.
10 (b) Any prior history of violations by the provider
11 relating to the delivery of health care programs which
12 resulted in either a criminal conviction or in administrative
13 sanction or penalty.
14 (c) Evidence of continued violation within the
15 provider's management control of Medicaid statutes, rules,
16 regulations, or policies after written notification to the
17 provider of improper practice or instance of violation.
18 (d) The effect, if any, on the quality of medical care
19 provided to Medicaid recipients as a result of the acts of the
20 provider.
21 (e) Any action by a licensing agency respecting the
22 provider in any state in which the provider operates or has
23 operated.
24 (f) The apparent impact on access by recipients to
25 Medicaid services if the provider is suspended or terminated,
26 in the best judgment of the agency.
27
28 The agency shall document the basis for all sanctioning
29 actions and recommendations.
30 (17) The agency may take action to sanction, suspend,
31 or terminate a particular provider working for a group
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1 provider, and may suspend or terminate Medicaid participation
2 at a specific location, rather than or in addition to taking
3 action against an entire group.
4 (18) The agency shall establish a process for
5 conducting followup reviews of a sampling of providers who
6 have a history of overpayment under the Medicaid program.
7 This process must consider the magnitude of previous fraud or
8 abuse and the potential effect of continued fraud or abuse on
9 Medicaid costs.
10 (19) In making a determination of overpayment to a
11 provider, the agency must use accepted and valid auditing,
12 accounting, analytical, statistical, or peer-review methods,
13 or combinations thereof. Appropriate statistical methods may
14 include, but are not limited to, sampling and extension to the
15 population, parametric and nonparametric statistics, tests of
16 hypotheses, and other generally accepted statistical methods.
17 Appropriate analytical methods may include, but are not
18 limited to, reviews to determine variances between the
19 quantities of products that a provider had on hand and
20 available to be purveyed to Medicaid recipients during the
21 review period and the quantities of the same products paid for
22 by the Medicaid program for the same period, taking into
23 appropriate consideration sales of the same products to
24 non-Medicaid customers during the same period. In meeting its
25 burden of proof in any administrative or court proceeding, the
26 agency may introduce the results of such statistical methods
27 as evidence of overpayment.
28 (20) When making a determination that an overpayment
29 has occurred, the agency shall prepare and issue an audit
30 report to the provider showing the calculation of
31 overpayments.
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1 (21) The audit report, supported by agency work
2 papers, showing an overpayment to a provider constitutes
3 evidence of the overpayment. A provider may not present or
4 elicit testimony, either on direct examination or
5 cross-examination in any court or administrative proceeding,
6 regarding the purchase or acquisition by any means of drugs,
7 goods, or supplies; sales or divestment by any means of drugs,
8 goods, or supplies; or inventory of drugs, goods, or supplies,
9 unless such acquisition, sales, divestment, or inventory is
10 documented by written invoices, written inventory records, or
11 other competent written documentary evidence maintained in the
12 normal course of the provider's business. Notwithstanding the
13 applicable rules of discovery, all documentation that will be
14 offered as evidence at an administrative hearing on a Medicaid
15 overpayment must be exchanged by all parties at least 14 days
16 before the administrative hearing or must be excluded from
17 consideration.
18 (22)(a) In an audit or investigation of a violation
19 committed by a provider which is conducted pursuant to this
20 section, the agency is entitled to recover all investigative,
21 legal, and expert witness costs if the agency's findings were
22 not contested by the provider or, if contested, the agency
23 ultimately prevailed.
24 (b) The agency has the burden of documenting the
25 costs, which include salaries and employee benefits and
26 out-of-pocket expenses. The amount of costs that may be
27 recovered must be reasonable in relation to the seriousness of
28 the violation and must be set taking into consideration the
29 financial resources, earning ability, and needs of the
30 provider, who has the burden of demonstrating such factors.
31
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1 (c) The provider may pay the costs over a period to be
2 determined by the agency if the agency determines that an
3 extreme hardship would result to the provider from immediate
4 full payment. Any default in payment of costs may be
5 collected by any means authorized by law.
6 (23) If the agency imposes an administrative sanction
7 under this section upon any provider or other person who is
8 regulated by another state entity, the agency shall notify
9 that other entity of the imposition of the sanction. Such
10 notification must include the provider's or person's name and
11 license number and the specific reasons for sanction.
12 (24)(a) The agency may withhold Medicaid payments, in
13 whole or in part, to a provider upon receipt of reliable
14 evidence that the circumstances giving rise to the need for a
15 withholding of payments involve fraud, willful
16 misrepresentation, or abuse under the Medicaid program, or a
17 crime committed while rendering goods or services to Medicaid
18 recipients, pending completion of legal proceedings. If it is
19 determined that fraud, willful misrepresentation, abuse, or a
20 crime did not occur, the payments withheld must be paid to the
21 provider within 14 days after such determination with interest
22 at the rate of 10 percent a year. Any money withheld in
23 accordance with this paragraph shall be placed in a suspended
24 account, readily accessible to the agency, so that any payment
25 ultimately due the provider shall be made within 14 days.
26 (b) Overpayments owed to the agency bear interest at
27 the rate of 10 percent per year from the date of determination
28 of the overpayment by the agency, and payment arrangements
29 must be made at the conclusion of legal proceedings. A
30 provider who does not enter into or adhere to an agreed-upon
31
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1 repayment schedule may be terminated by the agency for
2 nonpayment or partial payment.
3 (c) The agency, upon entry of a final agency order, a
4 judgment or order of a court of competent jurisdiction, or a
5 stipulation or settlement, may collect the moneys owed by all
6 means allowable by law, including, but not limited to,
7 notifying any fiscal intermediary of Medicare benefits that
8 the state has a superior right of payment. Upon receipt of
9 such written notification, the Medicare fiscal intermediary
10 shall remit to the state the sum claimed.
11 (25) The agency may impose administrative sanctions
12 against a Medicaid recipient, or the agency may seek any other
13 remedy provided by law, including, but not limited to, the
14 remedies provided in s. 812.035, if the agency finds that a
15 recipient has engaged in solicitation in violation of s.
16 409.920 or that the recipient has otherwise abused the
17 Medicaid program.
18 (26) When the Agency for Health Care Administration
19 has made a probable cause determination and alleged that an
20 overpayment to a Medicaid provider has occurred, the agency,
21 after notice to the provider, may:
22 (a) Withhold, and continue to withhold during the
23 pendency of an administrative hearing pursuant to chapter 120,
24 any medical assistance reimbursement payments until such time
25 as the overpayment is recovered, unless within 30 days after
26 receiving notice thereof the provider:
27 1. Makes repayment in full; or
28 2. Establishes a repayment plan that is satisfactory
29 to the Agency for Health Care Administration.
30 (b) Withhold, and continue to withhold during the
31 pendency of an administrative hearing pursuant to chapter 120,
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1 medical assistance reimbursement payments if the terms of a
2 repayment plan are not adhered to by the provider.
3
4 If a provider requests an administrative hearing pursuant to
5 chapter 120, such hearing must be conducted within 90 days
6 following receipt by the provider of the final audit report,
7 absent exceptionally good cause shown as determined by the
8 administrative law judge or hearing officer. Upon issuance of
9 a final order, the balance outstanding of the amount
10 determined to constitute the overpayment shall become due. Any
11 withholding of payments by the Agency for Health Care
12 Administration pursuant to this section shall be limited so
13 that the monthly medical assistance payment is not reduced by
14 more than 10 percent.
15 (27) Venue for all Medicaid program integrity
16 overpayment cases shall lie in Leon County, at the discretion
17 of the agency.
18 (28) Notwithstanding other provisions of law, the
19 agency and the Medicaid Fraud Control Unit of the Department
20 of Legal Affairs may review a provider's non-Medicaid-related
21 records in order to determine the total output of a provider's
22 practice to reconcile quantities of goods or services billed
23 to Medicaid against quantities of goods or services used in
24 the provider's total practice.
25 (29) The agency may terminate a provider's
26 participation in the Medicaid program if the provider fails to
27 reimburse an overpayment that has been determined by final
28 order within 35 days after the date of the final order, unless
29 the provider and the agency have entered into a repayment
30 agreement. If the final order is overturned on appeal, the
31 provider shall be reinstated.
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1 (30) If a provider requests an administrative hearing
2 pursuant to chapter 120, such hearing must be conducted within
3 90 days following assignment of an administrative law judge,
4 absent exceptionally good cause shown as determined by the
5 administrative law judge or hearing officer. Upon issuance of
6 a final order, the outstanding balance of the amount
7 determined to constitute the overpayment shall become due. If
8 a provider fails to make payments in full, fails to enter into
9 a satisfactory repayment plan, or fails to comply with the
10 terms of a repayment plan or settlement agreement, the agency
11 may withhold all medical assistance reimbursement payments
12 until the amount due is paid in full.
13 (31) Duly authorized agents and employees of the
14 agency and the Medicaid Fraud Control Unit of the Department
15 of Legal Affairs shall have the power to inspect, at all
16 reasonable hours and upon proper notice, the records of any
17 pharmacy, wholesale establishment, or manufacturer, or any
18 other place in the state in which drugs and medical supplies
19 are manufactured, packed, packaged, made, stored, sold, or
20 kept for sale, for the purpose of verifying the amount of
21 drugs and medical supplies ordered, delivered, or purchased by
22 a provider.
23 Section 17. Subsection (2) of section 409.915, Florida
24 Statutes, is amended to read:
25 409.915 County contributions to Medicaid.--Although
26 the state is responsible for the full portion of the state
27 share of the matching funds required for the Medicaid program,
28 in order to acquire a certain portion of these funds, the
29 state shall charge the counties for certain items of care and
30 service as provided in this section.
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1 (2) A county's participation must be 35 percent of the
2 total cost, or the applicable discounted cost paid by the
3 state for Medicaid recipients enrolled in health maintenance
4 organizations or prepaid health plans, of providing the items
5 listed in subsection (1), except that the payments for items
6 listed in paragraph (1)(b) may not exceed $140 $55 per month
7 per person.
8 Section 18. Subsections (7) and (8) of section
9 409.920, Florida Statutes, are amended to read:
10 409.920 Medicaid provider fraud.--
11 (7) The Attorney General shall conduct a statewide
12 program of Medicaid fraud control. To accomplish this purpose,
13 the Attorney General shall:
14 (a) Investigate the possible criminal violation of any
15 applicable state law pertaining to fraud in the administration
16 of the Medicaid program, in the provision of medical
17 assistance, or in the activities of providers of health care
18 under the Medicaid program.
19 (b) Investigate the alleged abuse or neglect of
20 patients in health care facilities receiving payments under
21 the Medicaid program, in coordination with the agency.
22 (c) Investigate the alleged misappropriation of
23 patients' private funds in health care facilities receiving
24 payments under the Medicaid program.
25 (d) Refer to the Office of Statewide Prosecution or
26 the appropriate state attorney all violations indicating a
27 substantial potential for criminal prosecution.
28 (e) Refer to the agency all suspected abusive
29 activities not of a criminal or fraudulent nature.
30 (f) Refer to the agency for collection each instance
31 of overpayment to a provider of health care under the Medicaid
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1 program which is discovered during the course of an
2 investigation.
3 (f)(g) Safeguard the privacy rights of all individuals
4 and provide safeguards to prevent the use of patient medical
5 records for any reason beyond the scope of a specific
6 investigation for fraud or abuse, or both, without the
7 patient's written consent.
8 (g) Publicize to state employees and the public the
9 ability of persons to bring suit under the provisions of the
10 Florida False Claims Act and the potential for the persons
11 bringing a civil action under the Florida False Claims Act to
12 obtain a monetary award.
13 (8) In carrying out the duties and responsibilities
14 under this section subsection, the Attorney General may:
15 (a) Enter upon the premises of any health care
16 provider, excluding a physician, participating in the Medicaid
17 program to examine all accounts and records that may, in any
18 manner, be relevant in determining the existence of fraud in
19 the Medicaid program, to investigate alleged abuse or neglect
20 of patients, or to investigate alleged misappropriation of
21 patients' private funds. A participating physician is required
22 to make available any accounts or records that may, in any
23 manner, be relevant in determining the existence of fraud in
24 the Medicaid program. The accounts or records of a
25 non-Medicaid patient may not be reviewed by, or turned over
26 to, the Attorney General without the patient's written
27 consent.
28 (b) Subpoena witnesses or materials, including medical
29 records relating to Medicaid recipients, within or outside the
30 state and, through any duly designated employee, administer
31
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1 oaths and affirmations and collect evidence for possible use
2 in either civil or criminal judicial proceedings.
3 (c) Request and receive the assistance of any state
4 attorney or law enforcement agency in the investigation and
5 prosecution of any violation of this section.
6 (d) Seek any civil remedy provided by law, including,
7 but not limited to, the remedies provided in ss.
8 68.081-68.092, s. 812.035, and this chapter.
9 (e) Refer to the agency for collection each instance
10 of overpayment to a provider of health care under the Medicaid
11 program which is discovered during the course of an
12 investigation.
13 Section 19. Effective July 1, 2002, subsection (1) and
14 paragraph (b) of subsection (4) of section 624.91, Florida
15 Statutes, as amended by section 20 of chapter 2001-377, Laws
16 of Florida, are amended to read:
17 624.91 The Florida Healthy Kids Corporation Act.--
18 (1) SHORT TITLE.--Sections 624.91-624.915 This section
19 may be cited as the "William G. 'Doc' Myers Healthy Kids
20 Corporation Act."
21 (4) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
22 (b) The Florida Healthy Kids Corporation shall phase
23 in a program to:
24 1. Organize school children groups to facilitate the
25 provision of comprehensive health insurance coverage to
26 children;
27 2. Arrange for the collection of any family, local
28 contributions, or employer payment or premium, in an amount to
29 be determined by the board of directors, to provide for
30 payment of premiums for comprehensive insurance coverage and
31 for the actual or estimated administrative expenses;
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1 3. Establish the administrative and accounting
2 procedures for the operation of the corporation;
3 4. Establish, with consultation from appropriate
4 professional organizations, standards for preventive health
5 services and providers and comprehensive insurance benefits
6 appropriate to children; provided that such standards for
7 rural areas shall not limit primary care providers to
8 board-certified pediatricians;
9 5. Establish eligibility criteria which children must
10 meet in order to participate in the program;
11 6. Establish procedures under which applicants to and
12 participants in the program may have grievances reviewed by an
13 impartial body and reported to the board of directors of the
14 corporation;
15 7. Establish participation criteria and, if
16 appropriate, contract with an authorized insurer, health
17 maintenance organization, or insurance administrator to
18 provide administrative services to the corporation;
19 8. Establish enrollment criteria which shall include
20 penalties or waiting periods of not fewer than 60 days for
21 reinstatement of coverage upon voluntary cancellation for
22 nonpayment of family premiums;
23 9. If a space is available, establish a special open
24 enrollment period of 30 days' duration for any child who is
25 enrolled in Medicaid or Medikids if such child loses Medicaid
26 or Medikids eligibility and becomes eligible for the Florida
27 Healthy Kids program;
28 10. Contract with authorized insurers or any provider
29 of health care services, meeting standards established by the
30 corporation, for the provision of comprehensive insurance
31 coverage to participants. Such standards shall include
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1 criteria under which the corporation may contract with more
2 than one provider of health care services in program sites.
3 Health plans shall be selected through a competitive bid
4 process. The selection of health plans shall be based
5 primarily on quality criteria established by the board. The
6 health plan selection criteria and scoring system, and the
7 scoring results, shall be available upon request for
8 inspection after the bids have been awarded;
9 11. Develop and implement a plan to publicize the
10 Florida Healthy Kids Corporation, the eligibility requirements
11 of the program, and the procedures for enrollment in the
12 program and to maintain public awareness of the corporation
13 and the program;
14 12. Secure staff necessary to properly administer the
15 corporation. Staff costs shall be funded from state and local
16 matching funds and such other private or public funds as
17 become available. The board of directors shall determine the
18 number of staff members necessary to administer the
19 corporation;
20 13. As appropriate, enter into contracts with local
21 school boards or other agencies to provide onsite information,
22 enrollment, and other services necessary to the operation of
23 the corporation;
24 14. Provide a report on an annual basis to the
25 Governor, Insurance Commissioner, Commissioner of Education,
26 Senate President, Speaker of the House of Representatives, and
27 Minority Leaders of the Senate and the House of
28 Representatives;
29 15. Annually determine the local match requirements
30 for each county under the formulas and procedure provided in
31 s. 624.915 Each fiscal year, establish a maximum number of
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1 participants by county, on a statewide basis, who may enroll
2 in the program without the benefit of local matching funds.
3 Thereafter, the corporation may establish local matching
4 requirements for supplemental participation in the program.
5 The corporation may vary local matching requirements and
6 enrollment by county depending on factors which may influence
7 the generation of local match, including, but not limited to,
8 population density, per capita income, existing local tax
9 effort, and other factors. The corporation also may accept
10 in-kind match in lieu of cash for the local match requirement
11 to the extent allowed by Title XXI of the Social Security Act;
12 and
13 16. Establish eligibility criteria, premium and
14 cost-sharing requirements, and benefit packages which conform
15 to the provisions of the Florida Kidcare program, as created
16 in ss. 409.810-409.820.; and
17 17. Notwithstanding the requirements of subparagraph
18 15. to the contrary, establish a local matching requirement of
19 $0.00 for the Title XXI program in each county of the state
20 for the 2001-2002 fiscal year. This subparagraph shall take
21 effect upon becoming a law and shall operate retroactively to
22 July 1, 2001. This subparagraph expires July 1, 2002.
23 Section 20. Section 624.915, Florida Statutes, is
24 created to read:
25 624.915 Local match requirement.--
26 (1) By May 1 of each year, the Florida Healthy Kids
27 Corporation established in s. 624.91 shall determine the local
28 match requirement for each county and provide written
29 notification to each county of the amount to be remitted to
30 the corporation for the following fiscal year.
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1 (a) The corporation shall first annually establish a
2 nonmatch enrollment allocation per county which does not
3 require any local matching funds. For the purpose of
4 determining the nonmatch enrollment allocation, each county
5 shall be assigned to one of three tiers based on the county's
6 population of children, using the most recently released
7 federal census data. Enrollment slots shall be allocated to
8 each tier; however, no county shall receive fewer than 500
9 slots. Enrollment slots shall not be reserved for any
10 particular county, and unused slots may be redistributed by
11 the corporation to accommodate increased enrollment in other
12 counties.
13 (b) The corporation shall then determine the county's
14 local match percentage rate. For the purpose of determining
15 the local match percentage rate, each county shall be assigned
16 to one of three tiers based on the county's economic census in
17 the year of the most recently released federal census data.
18 The local match percentage rate for the lowest tier shall be
19 greater than zero but not more than 5 percent, and it shall be
20 no greater than 15 percent for the highest tier.
21 (c) The corporation shall then calculate the local
22 match requirement for each county as the total annual
23 consideration paid by the corporation for the county's total
24 enrollee insurance premiums for the prior fiscal year, less
25 the value of the premiums for the county's nonmatch enrollment
26 for the same year, multiplied by the county's local match
27 percentage rate. The resulting local match requirement for
28 each county shall not be less than zero nor more than the
29 county paid in fiscal year 2000-2001.
30 (2) A county that disputes its tier assignment may
31 file a written grievance with the corporation for review by
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1 the corporation's board of directors. The board's decision
2 shall be final and not subject to further review.
3 (3) The corporation's board of directors shall
4 determine the timing and method for payment of the required
5 local match to the corporation. For purposes of meeting the
6 local match requirement, at least 90 percent of the county's
7 local match requirement must be eligible to match federal
8 Title XXI funds. Local matching funds must be in the form of
9 cash. In-kind contributions will not be accepted for purposes
10 of compliance with a county's local match requirement.
11 Section 21. Subsection (28) of section 393.063,
12 Florida Statutes, is amended to read:
13 393.063 Definitions.--For the purposes of this
14 chapter:
15 (28) "Intermediate care facility for the
16 developmentally disabled" or "ICF/DD" means a
17 state-owned-and-operated residential facility licensed and
18 certified in accordance with state law, and certified by the
19 Federal Government pursuant to the Social Security Act, as a
20 provider of Medicaid services to persons who are
21 developmentally disabled mentally retarded or who have related
22 conditions. The capacity of such a facility shall not be more
23 than 120 clients.
24 Section 22. Section 400.965, Florida Statutes, is
25 amended to read:
26 400.965 Action by agency against licensee; grounds.--
27 (1) Any of the following conditions constitute grounds
28 for action by the agency against a licensee:
29 (a) A misrepresentation of a material fact in the
30 application;
31
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1 (b) The commission of an intentional or negligent act
2 materially affecting the health or safety of residents of the
3 facility;
4 (c) A violation of any provision of this part or rules
5 adopted under this part; or
6 (d) The commission of any act constituting a ground
7 upon which application for a license may be denied.
8 (2) If the agency has a reasonable belief that any of
9 such conditions exists, it shall:
10 (a) In the case of an applicant for original
11 licensure, deny the application.
12 (b) In the case of an applicant for relicensure or a
13 current licensee, take administrative action as provided in s.
14 400.968 or s. 400.969 or injunctive action as authorized by s.
15 400.963.
16 (c) In the case of a facility operating without a
17 license, take injunctive action as authorized in s. 400.963.
18 Section 23. Subsection (4) of section 400.968, Florida
19 Statutes, is renumbered as section 400.969, Florida Statutes,
20 and amended to read:
21 400.969 Violation of part; penalties.--
22 (1)(4)(a) Except as provided in s. 400.967(3), a
23 violation of any provision of this part section or rules
24 adopted by the agency under this part section is punishable by
25 payment of an administrative or civil penalty not to exceed
26 $5,000.
27 (2)(b) A violation of this part section or of rules
28 adopted under this part section is a misdemeanor of the first
29 degree, punishable as provided in s. 775.082 or s. 775.083.
30 Each day of a continuing violation is a separate offense.
31
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1 Section 24. By January 1, 2003, the Agency for Health
2 Care Administration shall make recommendations to the
3 Legislature as to limits in the amount of home office
4 management and administrative fees which should be allowable
5 for reimbursement for Medicaid providers whose rates are set
6 on a cost-reimbursement basis.
7 Section 25. Except as otherwise provided herein, this
8 act shall take effect upon becoming a law.
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1 *****************************************
2 HOUSE SUMMARY
3
Requires certain collocation and coordination of the
4 Medicaid Fraud Control Unit of the Department of Legal
Affairs and the Medicaid program integrity program.
5 Revises procedures and requirements relating to
whistle-blower protection for reporting Medicaid fraud or
6 abuse. Authorizes the Agency for Health Care
Administration to take action against a regulated entity
7 under certain circumstances. Requires, as a condition of
Medicaid eligibility, consent for release of medical
8 records to the agency and the Medicaid Fraud Control
Unit. Revises eligibility standards for certain Medicaid
9 optional medical assistance and for the pharmaceutical
expense assistance program. Prescribes additional
10 requirements with respect to Medicaid provider
enrollment. Requires the agency to deny a provider's
11 application under certain circumstances. Provides a
finding that the act fulfills an important state
12 interest. Authorizes the agency to withhold provider
reimbursements if certain cost-reporting requirements are
13 not met. Revises requirements for the distribution of
funds recovered from third parties liable for payments
14 for medical care furnished to Medicaid recipients or
recovered from overpayments, to provide for distribution
15 to counties and local taxing districts. Revises
applicability of the disproportionate share/financial
16 assistance program for rural hospitals. Provides
requirements for contracts for Medicaid behavioral health
17 care services. Revises procedures relating to assignment
of a Medicaid recipient to a managed care plan or
18 MediPass provider. Requires the agency and the Medicaid
Fraud Control Unit to annually submit a joint report to
19 the Legislature. Defines "complaint" with respect to
Medicaid fraud or abuse. Specifies additional
20 requirements for the Medicaid program integrity program
and the Medicaid Fraud Control Unit. Requires imposition
21 of sanctions or disincentives, except under certain
circumstances, and provides additional sanctions and
22 disincentives. Provides additional grounds for
termination of a provider's participation in the Medicaid
23 program. Provides additional requirements for
administrative hearings. Provides additional grounds for
24 withholding payments to a provider. Authorizes the agency
and the Medicaid Fraud Control Unit to review certain
25 records. Revises a limitation on county contributions to
Medicaid costs. Provides additional duties of the
26 Attorney General with respect to Medicaid fraud control.
Revises duties of the Florida Healthy Kids Corporation
27 regarding annual determination of participation and
prescribes duties in establishing local match
28 requirements. Revises definition of "intermediate care
facility for the developmentally disabled" and provides
29 penalties applicable to pt. XI of ch. 400, F.S., which
relates to such facilities. Requires the agency to make
30 recommendations to the Legislature regarding limitations
on certain Medicaid provider reimbursements. See bill for
31 details.
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