House Bill hb1975e1
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HB 1975, First Engrossed/ntc
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. Subsection (2) of section 409.904, Florida
17 Statutes, as amended by section 2 of chapter 2001-377, Laws of
18 Florida, is amended to read:
19 409.904 Optional payments for eligible persons.--The
20 agency may make payments for medical assistance and related
21 services on behalf of the following persons who are determined
22 to be eligible subject to the income, assets, and categorical
23 eligibility tests set forth in federal and state law. Payment
24 on behalf of these Medicaid eligible persons is subject to the
25 availability of moneys and any limitations established by the
26 General Appropriations Act or chapter 216.
27 (2)(a) A pregnant woman who would otherwise qualify
28 for Medicaid under s. 409.903(5) except for her level of
29 income and whose assets fall within the limits established by
30 the Department of Children and Family Services for the
31
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1 medically needy. A pregnant woman who applies for medically
2 needy eligibility may not be made presumptively eligible.
3 (b) A child under age 21 who would otherwise qualify
4 for Medicaid or the Florida Kidcare program except for the
5 family's level of income and whose assets fall within the
6 limits established by the Department of Children and Family
7 Services for the medically needy. A family, a pregnant woman,
8 a child under age 18, a person age 65 or over, or a blind or
9 disabled person who would be eligible under any group listed
10 in s. 409.903(1), (2), or (3), except that the income or
11 assets of such family or person exceed established
12 limitations. For a family or person in this group, medical
13 expenses are deductible from income in accordance with federal
14 requirements in order to make a determination of eligibility.
15 Expenses used to meet spend-down liability are not
16 reimbursable by Medicaid. The medically-needy income levels
17 in effect on July 1, 2001, are increased by $270 effective
18 July 1, 2002. A family or person in this group, which group
19 is known as the "medically needy," is eligible to receive the
20 same services as other Medicaid recipients, with the exception
21 of services in skilled nursing facilities and intermediate
22 care facilities for the developmentally disabled.
23 Section 8. Present subsections (8) and (10) of section
24 409.904, Florida Statutes, are amended, present subsections
25 (9), (10), and (11) are renumbered as subsections (10), (11),
26 and (12), respectively, and a new subsection (9) is added to
27 said section, to read:
28 409.904 Optional payments for eligible persons.--The
29 agency may make payments for medical assistance and related
30 services on behalf of the following persons who are determined
31 to be eligible subject to the income, assets, and categorical
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1 eligibility tests set forth in federal and state law. Payment
2 on behalf of these Medicaid eligible persons is subject to the
3 availability of moneys and any limitations established by the
4 General Appropriations Act or chapter 216.
5 (8) An unborn child or a child under 1 year of age who
6 lives in a family that has an income above 150 185 percent but
7 not in excess of 200 percent of the most recently published
8 federal poverty level, but which is at or below 200 percent of
9 such poverty level. Countable income shall be determined in
10 accordance with state and federal regulation. For an unborn
11 child, coverage is dependent upon federal approval of coverage
12 through Title XXI of the Social Security Act. In determining
13 the eligibility of such child, an assets test is not required.
14 A child who is eligible for Medicaid under this subsection
15 must be offered the opportunity, subject to federal rules, to
16 be made presumptively eligible.
17 (9) A pregnant woman for the duration of her pregnancy
18 and for the postpartum period as defined in federal law and
19 regulation, who has an income above 150 percent but not in
20 excess of 185 percent of the federal poverty level. Countable
21 income shall be determined in accordance with state and
22 federal regulation. A pregnant woman who applies for
23 eligibility for the Medicaid program shall be offered the
24 opportunity, subject to federal regulations, to be made
25 presumptively eligible. Coverage for a pregnant woman during
26 her pregnancy shall not be available should coverage become
27 available under Title XXI of the Social Security Act as
28 provided in subsection (8).
29 (11)(10)(a) Eligible women with incomes at or below
30 200 percent of the federal poverty level and under age 65, for
31 cancer treatment pursuant to the federal Breast and Cervical
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1 Cancer Prevention and Treatment Act of 2000, screened through
2 the Mary Brogan National Breast and Cervical Cancer Early
3 Detection Program established under s. 381.93.
4 (b) A woman who has not attained 65 years of age and
5 who has been screened for breast or cervical cancer by a
6 qualified entity under the Mary Brogan Breast and Cervical
7 Cancer Early Detection Program of the Department of Health and
8 needs treatment for breast or cervical cancer and is not
9 otherwise covered under creditable coverage, as defined in s.
10 2701(c) of the Public Health Service Act. For purposes of this
11 subsection, the term "qualified entity" means a county public
12 health department or other entity that has contracted with the
13 Department of Health to provide breast and cervical cancer
14 screening services paid for under this act. In determining the
15 eligibility of such a woman, an assets test is not required. A
16 presumptive eligibility period begins on the date on which all
17 eligibility criteria appear to be met and ends on the date
18 determination is made with respect to the eligibility of such
19 woman for services under the state plan or, in the case of
20 such a woman who does not file an application, by the last day
21 of the month following the month in which the presumptive
22 eligibility determination is made. A woman is eligible until
23 she gains creditable coverage, until treatment is no longer
24 necessary, or until attainment of 65 years of age.
25 Section 9. Effective July 1, 2002, subsection (2) of
26 section 409.9065, Florida Statutes, is amended to read:
27 409.9065 Pharmaceutical expense assistance.--
28 (2) ELIGIBILITY.--Eligibility for the program is
29 limited to those individuals who qualify for limited
30 assistance under the Florida Medicaid program as a result of
31 being dually eligible for both Medicare and Medicaid, but
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1 whose limited assistance or Medicare coverage does not include
2 any pharmacy benefit. To the extent that funds are
3 appropriated, specifically eligible are low-income senior
4 citizens who:
5 (a) Are Florida residents age 65 and over;
6 (b) Have an income between 90 and 120 percent of the
7 federal poverty level, or an income between 90 and 150 percent
8 of the federal poverty level if the Federal Government raises
9 the Medicaid match to 150 percent of the federal poverty
10 level;
11 (c) Are eligible for both Medicare and Medicaid;
12 (d) Are not enrolled in a Medicare health maintenance
13 organization that provides a pharmacy benefit; and
14 (e) Request to be enrolled in the program.
15 Section 10. Subsections (7) and (9) of section
16 409.907, Florida Statutes, as amended by section 6 of chapter
17 2001-377, Laws of Florida, are amended to read:
18 409.907 Medicaid provider agreements.--The agency may
19 make payments for medical assistance and related services
20 rendered to Medicaid recipients only to an individual or
21 entity who has a provider agreement in effect with the agency,
22 who is performing services or supplying goods in accordance
23 with federal, state, and local law, and who agrees that no
24 person shall, on the grounds of handicap, race, color, or
25 national origin, or for any other reason, be subjected to
26 discrimination under any program or activity for which the
27 provider receives payment from the agency.
28 (7) The agency may require, as a condition of
29 participating in the Medicaid program and before entering into
30 the provider agreement, that the provider submit information,
31 in an initial and any required renewal applications,
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1 concerning the professional, business, and personal background
2 of the provider and permit an onsite inspection of the
3 provider's service location by agency staff or other personnel
4 designated by the agency to perform this function. After
5 receipt of the fully completed application of a new provider,
6 the agency shall perform random onsite inspection of the
7 provider's service location to assist in determining the
8 applicant's ability to provide the services that the applicant
9 is proposing to provide for Medicaid reimbursement. The agency
10 is not required to perform an onsite inspection of a provider
11 or program that is licensed by the agency or the Department of
12 Health. As a continuing condition of participation in the
13 Medicaid program, a provider shall immediately notify the
14 agency of any current or pending bankruptcy filing. Before
15 entering into the provider agreement, or as a condition of
16 continuing participation in the Medicaid program, the agency
17 may also require that Medicaid providers reimbursed on a
18 fee-for-services basis or fee schedule basis which is not
19 cost-based, post a surety bond not to exceed $50,000 or the
20 total amount billed by the provider to the program during the
21 current or most recent calendar year, whichever is greater.
22 For new providers, the amount of the surety bond shall be
23 determined by the agency based on the provider's estimate of
24 its first year's billing. If the provider's billing during the
25 first year exceeds the bond amount, the agency may require the
26 provider to acquire an additional bond equal to the actual
27 billing level of the provider. A provider's bond shall not
28 exceed $50,000 if a physician or group of physicians licensed
29 under chapter 458, chapter 459, or chapter 460 has a 50
30 percent or greater ownership interest in the provider or if
31 the provider is an assisted living facility licensed under
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1 part III of chapter 400. The bonds permitted by this section
2 are in addition to the bonds referenced in s. 400.179(4)(d).
3 If the provider is a corporation, partnership, association, or
4 other entity, the agency may require the provider to submit
5 information concerning the background of that entity and of
6 any principal of the entity, including any partner or
7 shareholder having an ownership interest in the entity equal
8 to 5 percent or greater, and any treating provider who
9 participates in or intends to participate in Medicaid through
10 the entity. The information must include:
11 (a) Proof of holding a valid license or operating
12 certificate, as applicable, if required by the state or local
13 jurisdiction in which the provider is located or if required
14 by the Federal Government.
15 (b) Information concerning any prior violation, fine,
16 suspension, termination, or other administrative action taken
17 under the Medicaid laws, rules, or regulations of this state
18 or of any other state or the Federal Government; any prior
19 violation of the laws, rules, or regulations relating to the
20 Medicare program; any prior violation of the rules or
21 regulations of any other public or private insurer; and any
22 prior violation of the laws, rules, or regulations of any
23 regulatory body of this or any other state.
24 (c) Full and accurate disclosure of any financial or
25 ownership interest that the provider, or any principal,
26 partner, or major shareholder thereof, may hold in any other
27 Medicaid provider or health care related entity or any other
28 entity that is licensed by the state to provide health or
29 residential care and treatment to persons.
30
31
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1 (d) If a group provider, identification of all members
2 of the group and attestation that all members of the group are
3 enrolled in or have applied to enroll in the Medicaid program.
4 (9) Upon receipt of a completed, signed, and dated
5 application, and completion of any necessary background
6 investigation and criminal history record check, the agency
7 must either:
8 (a) Enroll the applicant as a Medicaid provider no
9 earlier than the effective date of the approval of the
10 provider application. With respect to providers who were
11 recently granted a change of ownership and those who primarily
12 provide emergency medical services transportation or emergency
13 services and care pursuant to s. 401.45 or s. 395.1041, and
14 out-of-state providers, upon approval of the provider
15 application, the effective date of approval is considered to
16 be the date the agency receives the provider application; or
17 (b) Deny the application if the agency finds that it
18 is in the best interest of the Medicaid program to do so. The
19 agency may consider the factors listed in subsection (10), as
20 well as any other factor that could affect the effective and
21 efficient administration of the program, including, but not
22 limited to, the applicant's demonstrated ability to provide
23 services, conduct business, and operate a financially viable
24 concern; the current availability of medical care, services,
25 or supplies to recipients, taking into account geographic
26 location and reasonable travel time; the number of providers
27 of the same type already enrolled in the same geographic area;
28 and the credentials, experience, success, and patient outcomes
29 of the provider for the services that it is making application
30 to provide in the Medicaid program. The agency shall deny the
31 application if the agency finds that a provider; any officer,
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1 director, agent, managing employee, or affiliated person; or
2 any partner or shareholder having an ownership interest of 5
3 percent or more in the provider if the provider is a
4 corporation, partnership, or other business entity has failed
5 to pay all outstanding fines or overpayments assessed by final
6 order of the agency or final order of the Centers for Medicare
7 and Medicaid Services, unless the provider agrees to a
8 repayment plan that includes withholding Medicaid
9 reimbursement until the amount due is paid in full.
10 Section 11. The Legislature determines and declares
11 that this act fulfills an important state interest.
12 Section 12. Section 409.908, Florida Statutes, as
13 amended by section 7 of chapter 2001-377, Laws of Florida, is
14 amended to read:
15 409.908 Reimbursement of Medicaid providers.--Subject
16 to specific appropriations, the agency shall reimburse
17 Medicaid providers, in accordance with state and federal law,
18 according to methodologies set forth in the rules of the
19 agency and in policy manuals and handbooks incorporated by
20 reference therein. These methodologies may include fee
21 schedules, reimbursement methods based on cost reporting,
22 negotiated fees, competitive bidding pursuant to s. 287.057,
23 and other mechanisms the agency considers efficient and
24 effective for purchasing services or goods on behalf of
25 recipients. If a provider is reimbursed based on cost
26 reporting and fails to submit cost reports at the time
27 specified by the agency, the agency may withhold reimbursement
28 to the provider until a cost report is submitted that is
29 acceptable to the agency. Payment for Medicaid compensable
30 services made on behalf of Medicaid eligible persons is
31 subject to the availability of moneys and any limitations or
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1 directions provided for in the General Appropriations Act or
2 chapter 216. Further, nothing in this section shall be
3 construed to prevent or limit the agency from adjusting fees,
4 reimbursement rates, lengths of stay, number of visits, or
5 number of services, or making any other adjustments necessary
6 to comply with the availability of moneys and any limitations
7 or directions provided for in the General Appropriations Act,
8 provided the adjustment is consistent with legislative intent.
9 (1) Reimbursement to hospitals licensed under part I
10 of chapter 395 must be made prospectively or on the basis of
11 negotiation.
12 (a) Reimbursement for inpatient care is limited as
13 provided for in s. 409.905(5), except for:
14 1. The raising of rate reimbursement caps, excluding
15 rural hospitals.
16 2. Recognition of the costs of graduate medical
17 education.
18 3. Other methodologies recognized in the General
19 Appropriations Act.
20 4. Hospital inpatient rates shall be reduced by 6
21 percent effective July 1, 2001, and restored effective April
22 1, 2002.
23
24 During the years funds are transferred from the Department of
25 Health, any reimbursement supported by such funds shall be
26 subject to certification by the Department of Health that the
27 hospital has complied with s. 381.0403. The agency is
28 authorized to receive funds from state entities, including,
29 but not limited to, the Department of Health, local
30 governments, and other local political subdivisions, for the
31 purpose of making special exception payments, including
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1 federal matching funds, through the Medicaid inpatient
2 reimbursement methodologies. Funds received from state
3 entities or local governments for this purpose shall be
4 separately accounted for and shall not be commingled with
5 other state or local funds in any manner. The agency may
6 certify all local governmental funds used as state match under
7 Title XIX of the Social Security Act, to the extent that the
8 identified local health care provider that is otherwise
9 entitled to and is contracted to receive such local funds is
10 the benefactor under the state's Medicaid program as
11 determined under the General Appropriations Act and pursuant
12 to an agreement between the Agency for Health Care
13 Administration and the local governmental entity. The local
14 governmental entity shall use a certification form prescribed
15 by the agency. At a minimum, the certification form shall
16 identify the amount being certified and describe the
17 relationship between the certifying local governmental entity
18 and the local health care provider. The agency shall prepare
19 an annual statement of impact which documents the specific
20 activities undertaken during the previous fiscal year pursuant
21 to this paragraph, to be submitted to the Legislature no later
22 than January 1, annually.
23 (b) Reimbursement for hospital outpatient care is
24 limited to $1,500 per state fiscal year per recipient, except
25 for:
26 1. Such care provided to a Medicaid recipient under
27 age 21, in which case the only limitation is medical
28 necessity.
29 2. Renal dialysis services.
30 3. Other exceptions made by the agency.
31
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HB 1975, First Engrossed/ntc
1 The agency is authorized to receive funds from state entities,
2 including, but not limited to, the Department of Health, the
3 Board of Regents, local governments, and other local political
4 subdivisions, for the purpose of making payments, including
5 federal matching funds, through the Medicaid outpatient
6 reimbursement methodologies. Funds received from state
7 entities and local governments for this purpose shall be
8 separately accounted for and shall not be commingled with
9 other state or local funds in any manner.
10 (c) Hospitals that provide services to a
11 disproportionate share of low-income Medicaid recipients, or
12 that participate in the regional perinatal intensive care
13 center program under chapter 383, or that participate in the
14 statutory teaching hospital disproportionate share program may
15 receive additional reimbursement. The total amount of payment
16 for disproportionate share hospitals shall be fixed by the
17 General Appropriations Act. The computation of these payments
18 must be made in compliance with all federal regulations and
19 the methodologies described in ss. 409.911, 409.9112, and
20 409.9113.
21 (d) The agency is authorized to limit inflationary
22 increases for outpatient hospital services as directed by the
23 General Appropriations Act.
24 (2)(a)1. Reimbursement to nursing homes licensed under
25 part II of chapter 400 and state-owned-and-operated
26 intermediate care facilities for the developmentally disabled
27 licensed under chapter 393 must be made prospectively.
28 2. Unless otherwise limited or directed in the General
29 Appropriations Act, reimbursement to hospitals licensed under
30 part I of chapter 395 for the provision of swing-bed nursing
31 home services must be made on the basis of the average
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1 statewide nursing home payment, and reimbursement to a
2 hospital licensed under part I of chapter 395 for the
3 provision of skilled nursing services must be made on the
4 basis of the average nursing home payment for those services
5 in the county in which the hospital is located. When a
6 hospital is located in a county that does not have any
7 community nursing homes, reimbursement must be determined by
8 averaging the nursing home payments, in counties that surround
9 the county in which the hospital is located. Reimbursement to
10 hospitals, including Medicaid payment of Medicare copayments,
11 for skilled nursing services shall be limited to 30 days,
12 unless a prior authorization has been obtained from the
13 agency. Medicaid reimbursement may be extended by the agency
14 beyond 30 days, and approval must be based upon verification
15 by the patient's physician that the patient requires
16 short-term rehabilitative and recuperative services only, in
17 which case an extension of no more than 15 days may be
18 approved. Reimbursement to a hospital licensed under part I of
19 chapter 395 for the temporary provision of skilled nursing
20 services to nursing home residents who have been displaced as
21 the result of a natural disaster or other emergency may not
22 exceed the average county nursing home payment for those
23 services in the county in which the hospital is located and is
24 limited to the period of time which the agency considers
25 necessary for continued placement of the nursing home
26 residents in the hospital.
27 (b) Subject to any limitations or directions provided
28 for in the General Appropriations Act, the agency shall
29 establish and implement a Florida Title XIX Long-Term Care
30 Reimbursement Plan (Medicaid) for nursing home care in order
31 to provide care and services in conformance with the
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HB 1975, First Engrossed/ntc
1 applicable state and federal laws, rules, regulations, and
2 quality and safety standards and to ensure that individuals
3 eligible for medical assistance have reasonable geographic
4 access to such care.
5 1. Changes of ownership or of licensed operator do not
6 qualify for increases in reimbursement rates associated with
7 the change of ownership or of licensed operator. The agency
8 shall amend the Title XIX Long Term Care Reimbursement Plan to
9 provide that the initial nursing home reimbursement rates, for
10 the operating, patient care, and MAR components, associated
11 with related and unrelated party changes of ownership or
12 licensed operator filed on or after September 1, 2001, are
13 equivalent to the previous owner's reimbursement rate.
14 2. The agency shall amend the long-term care
15 reimbursement plan and cost reporting system to create direct
16 care and indirect care subcomponents of the patient care
17 component of the per diem rate. These two subcomponents
18 together shall equal the patient care component of the per
19 diem rate. Separate cost-based ceilings shall be calculated
20 for each patient care subcomponent. The direct care
21 subcomponent of the per diem rate shall be limited by the
22 cost-based class ceiling, and the indirect care subcomponent
23 shall be limited by the lower of the cost-based class ceiling,
24 by the target rate class ceiling, or by the individual
25 provider target. The agency shall adjust the patient care
26 component effective January 1, 2002. The cost to adjust the
27 direct care subcomponent shall be net of the total funds
28 previously allocated for the case mix add-on. The agency shall
29 make the required changes to the nursing home cost reporting
30 forms to implement this requirement effective January 1, 2002.
31
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1 3. The direct care subcomponent shall include salaries
2 and benefits of direct care staff providing nursing services
3 including registered nurses, licensed practical nurses, and
4 certified nursing assistants who deliver care directly to
5 residents in the nursing home facility. This excludes nursing
6 administration, MDS, and care plan coordinators, staff
7 development, and staffing coordinator.
8 4. All other patient care costs shall be included in
9 the indirect care cost subcomponent of the patient care per
10 diem rate. There shall be no costs directly or indirectly
11 allocated to the direct care subcomponent from a home office
12 or management company.
13 5. On July 1 of each year, the agency shall report to
14 the Legislature direct and indirect care costs, including
15 average direct and indirect care costs per resident per
16 facility and direct care and indirect care salaries and
17 benefits per category of staff member per facility.
18 6. Under the plan, interim rate adjustments shall not
19 be granted to reflect increases in the cost of general or
20 professional liability insurance for nursing homes unless the
21 following criteria are met: have at least a 65 percent
22 Medicaid utilization in the most recent cost report submitted
23 to the agency, and the increase in general or professional
24 liability costs to the facility for the most recent policy
25 period affects the total Medicaid per diem by at least 5
26 percent. This rate adjustment shall not result in the per diem
27 exceeding the class ceiling. This provision shall be
28 implemented to the extent existing appropriations are
29 available.
30
31
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1 It is the intent of the Legislature that the reimbursement
2 plan achieve the goal of providing access to health care for
3 nursing home residents who require large amounts of care while
4 encouraging diversion services as an alternative to nursing
5 home care for residents who can be served within the
6 community. The agency shall base the establishment of any
7 maximum rate of payment, whether overall or component, on the
8 available moneys as provided for in the General Appropriations
9 Act. The agency may base the maximum rate of payment on the
10 results of scientifically valid analysis and conclusions
11 derived from objective statistical data pertinent to the
12 particular maximum rate of payment.
13 (3) Subject to any limitations or directions provided
14 for in the General Appropriations Act, the following Medicaid
15 services and goods may be reimbursed on a fee-for-service
16 basis. For each allowable service or goods furnished in
17 accordance with Medicaid rules, policy manuals, handbooks, and
18 state and federal law, the payment shall be the amount billed
19 by the provider, the provider's usual and customary charge, or
20 the maximum allowable fee established by the agency, whichever
21 amount is less, with the exception of those services or goods
22 for which the agency makes payment using a methodology based
23 on capitation rates, average costs, or negotiated fees.
24 (a) Advanced registered nurse practitioner services.
25 (b) Birth center services.
26 (c) Chiropractic services.
27 (d) Community mental health services.
28 (e) Dental services, including oral and maxillofacial
29 surgery.
30 (f) Durable medical equipment.
31 (g) Hearing services.
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1 (h) Occupational therapy for Medicaid recipients under
2 age 21.
3 (i) Optometric services.
4 (j) Orthodontic services.
5 (k) Personal care for Medicaid recipients under age
6 21.
7 (l) Physical therapy for Medicaid recipients under age
8 21.
9 (m) Physician assistant services.
10 (n) Podiatric services.
11 (o) Portable X-ray services.
12 (p) Private-duty nursing for Medicaid recipients under
13 age 21.
14 (q) Registered nurse first assistant services.
15 (r) Respiratory therapy for Medicaid recipients under
16 age 21.
17 (s) Speech therapy for Medicaid recipients under age
18 21.
19 (t) Visual services.
20 (4) Subject to any limitations or directions provided
21 for in the General Appropriations Act, alternative health
22 plans, health maintenance organizations, and prepaid health
23 plans shall be reimbursed a fixed, prepaid amount negotiated,
24 or competitively bid pursuant to s. 287.057, by the agency and
25 prospectively paid to the provider monthly for each Medicaid
26 recipient enrolled. The amount may not exceed the average
27 amount the agency determines it would have paid, based on
28 claims experience, for recipients in the same or similar
29 category of eligibility. The agency shall calculate
30 capitation rates on a regional basis and, beginning September
31 1, 1995, shall include age-band differentials in such
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1 calculations. Effective July 1, 2001, the cost of exempting
2 statutory teaching hospitals, specialty hospitals, and
3 community hospital education program hospitals from
4 reimbursement ceilings and the cost of special Medicaid
5 payments shall not be included in premiums paid to health
6 maintenance organizations or prepaid health care plans. Each
7 rate semester, the agency shall calculate and publish a
8 Medicaid hospital rate schedule that does not reflect either
9 special Medicaid payments or the elimination of rate
10 reimbursement ceilings, to be used by hospitals and Medicaid
11 health maintenance organizations, in order to determine the
12 Medicaid rate referred to in ss. 409.912(16), 409.9128(5), and
13 641.513(6).
14 (5) An ambulatory surgical center shall be reimbursed
15 the lesser of the amount billed by the provider or the
16 Medicare-established allowable amount for the facility.
17 (6) A provider of early and periodic screening,
18 diagnosis, and treatment services to Medicaid recipients who
19 are children under age 21 shall be reimbursed using an
20 all-inclusive rate stipulated in a fee schedule established by
21 the agency. A provider of the visual, dental, and hearing
22 components of such services shall be reimbursed the lesser of
23 the amount billed by the provider or the Medicaid maximum
24 allowable fee established by the agency.
25 (7) A provider of family planning services shall be
26 reimbursed the lesser of the amount billed by the provider or
27 an all-inclusive amount per type of visit for physicians and
28 advanced registered nurse practitioners, as established by the
29 agency in a fee schedule.
30 (8) A provider of home-based or community-based
31 services rendered pursuant to a federally approved waiver
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1 shall be reimbursed based on an established or negotiated rate
2 for each service. These rates shall be established according
3 to an analysis of the expenditure history and prospective
4 budget developed by each contract provider participating in
5 the waiver program, or under any other methodology adopted by
6 the agency and approved by the Federal Government in
7 accordance with the waiver. Effective July 1, 1996, privately
8 owned and operated community-based residential facilities
9 which meet agency requirements and which formerly received
10 Medicaid reimbursement for the optional intermediate care
11 facility for the mentally retarded service may participate in
12 the developmental services waiver as part of a
13 home-and-community-based continuum of care for Medicaid
14 recipients who receive waiver services.
15 (9) A provider of home health care services or of
16 medical supplies and appliances shall be reimbursed on the
17 basis of competitive bidding or for the lesser of the amount
18 billed by the provider or the agency's established maximum
19 allowable amount, except that, in the case of the rental of
20 durable medical equipment, the total rental payments may not
21 exceed the purchase price of the equipment over its expected
22 useful life or the agency's established maximum allowable
23 amount, whichever amount is less.
24 (10) A hospice shall be reimbursed through a
25 prospective system for each Medicaid hospice patient at
26 Medicaid rates using the methodology established for hospice
27 reimbursement pursuant to Title XVIII of the federal Social
28 Security Act.
29 (11) A provider of independent laboratory services
30 shall be reimbursed on the basis of competitive bidding or for
31 the least of the amount billed by the provider, the provider's
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HB 1975, First Engrossed/ntc
1 usual and customary charge, or the Medicaid maximum allowable
2 fee established by the agency.
3 (12)(a) A physician shall be reimbursed the lesser of
4 the amount billed by the provider or the Medicaid maximum
5 allowable fee established by the agency.
6 (b) The agency shall adopt a fee schedule, subject to
7 any limitations or directions provided for in the General
8 Appropriations Act, based on a resource-based relative value
9 scale for pricing Medicaid physician services. Under this fee
10 schedule, physicians shall be paid a dollar amount for each
11 service based on the average resources required to provide the
12 service, including, but not limited to, estimates of average
13 physician time and effort, practice expense, and the costs of
14 professional liability insurance. The fee schedule shall
15 provide increased reimbursement for preventive and primary
16 care services and lowered reimbursement for specialty services
17 by using at least two conversion factors, one for cognitive
18 services and another for procedural services. The fee
19 schedule shall not increase total Medicaid physician
20 expenditures unless moneys are available, and shall be phased
21 in over a 2-year period beginning on July 1, 1994. The Agency
22 for Health Care Administration shall seek the advice of a
23 16-member advisory panel in formulating and adopting the fee
24 schedule. The panel shall consist of Medicaid physicians
25 licensed under chapters 458 and 459 and shall be composed of
26 50 percent primary care physicians and 50 percent specialty
27 care physicians.
28 (c) Notwithstanding paragraph (b), reimbursement fees
29 to physicians for providing total obstetrical services to
30 Medicaid recipients, which include prenatal, delivery, and
31 postpartum care, shall be at least $1,500 per delivery for a
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HB 1975, First Engrossed/ntc
1 pregnant woman with low medical risk and at least $2,000 per
2 delivery for a pregnant woman with high medical risk. However,
3 reimbursement to physicians working in Regional Perinatal
4 Intensive Care Centers designated pursuant to chapter 383, for
5 services to certain pregnant Medicaid recipients with a high
6 medical risk, may be made according to obstetrical care and
7 neonatal care groupings and rates established by the agency.
8 Nurse midwives licensed under part I of chapter 464 or
9 midwives licensed under chapter 467 shall be reimbursed at no
10 less than 80 percent of the low medical risk fee. The agency
11 shall by rule determine, for the purpose of this paragraph,
12 what constitutes a high or low medical risk pregnant woman and
13 shall not pay more based solely on the fact that a caesarean
14 section was performed, rather than a vaginal delivery. The
15 agency shall by rule determine a prorated payment for
16 obstetrical services in cases where only part of the total
17 prenatal, delivery, or postpartum care was performed. The
18 Department of Health shall adopt rules for appropriate
19 insurance coverage for midwives licensed under chapter 467.
20 Prior to the issuance and renewal of an active license, or
21 reactivation of an inactive license for midwives licensed
22 under chapter 467, such licensees shall submit proof of
23 coverage with each application.
24 (d) For the 2001-2002 fiscal year only and if
25 necessary to meet the requirements for grants and donations
26 for the special Medicaid payments authorized in the 2001-2002
27 General Appropriations Act, the agency may make special
28 Medicaid payments to qualified Medicaid providers designated
29 by the agency, notwithstanding any provision of this
30 subsection to the contrary, and may use intergovernmental
31
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HB 1975, First Engrossed/ntc
1 transfers from state entities to serve as the state share of
2 such payments.
3 (13) Medicare premiums for persons eligible for both
4 Medicare and Medicaid coverage shall be paid at the rates
5 established by Title XVIII of the Social Security Act. For
6 Medicare services rendered to Medicaid-eligible persons,
7 Medicaid shall pay Medicare deductibles and coinsurance as
8 follows:
9 (a) Medicaid shall make no payment toward deductibles
10 and coinsurance for any service that is not covered by
11 Medicaid.
12 (b) Medicaid's financial obligation for deductibles
13 and coinsurance payments shall be based on Medicare allowable
14 fees, not on a provider's billed charges.
15 (c) Medicaid will pay no portion of Medicare
16 deductibles and coinsurance when payment that Medicare has
17 made for the service equals or exceeds what Medicaid would
18 have paid if it had been the sole payor. The combined payment
19 of Medicare and Medicaid shall not exceed the amount Medicaid
20 would have paid had it been the sole payor. The Legislature
21 finds that there has been confusion regarding the
22 reimbursement for services rendered to dually eligible
23 Medicare beneficiaries. Accordingly, the Legislature clarifies
24 that it has always been the intent of the Legislature before
25 and after 1991 that, in reimbursing in accordance with fees
26 established by Title XVIII for premiums, deductibles, and
27 coinsurance for Medicare services rendered by physicians to
28 Medicaid eligible persons, physicians be reimbursed at the
29 lesser of the amount billed by the physician or the Medicaid
30 maximum allowable fee established by the Agency for Health
31 Care Administration, as is permitted by federal law. It has
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HB 1975, First Engrossed/ntc
1 never been the intent of the Legislature with regard to such
2 services rendered by physicians that Medicaid be required to
3 provide any payment for deductibles, coinsurance, or
4 copayments for Medicare cost sharing, or any expenses incurred
5 relating thereto, in excess of the payment amount provided for
6 under the State Medicaid plan for such service. This payment
7 methodology is applicable even in those situations in which
8 the payment for Medicare cost sharing for a qualified Medicare
9 beneficiary with respect to an item or service is reduced or
10 eliminated. This expression of the Legislature is in
11 clarification of existing law and shall apply to payment for,
12 and with respect to provider agreements with respect to, items
13 or services furnished on or after the effective date of this
14 act. This paragraph applies to payment by Medicaid for items
15 and services furnished before the effective date of this act
16 if such payment is the subject of a lawsuit that is based on
17 the provisions of this section, and that is pending as of, or
18 is initiated after, the effective date of this act.
19 (d) Notwithstanding paragraphs (a)-(c):
20 1. Medicaid payments for Nursing Home Medicare part A
21 coinsurance shall be the lesser of the Medicare coinsurance
22 amount or the Medicaid nursing home per diem rate.
23 2. Medicaid shall pay all deductibles and coinsurance
24 for Medicare-eligible recipients receiving freestanding end
25 stage renal dialysis center services.
26 3. Medicaid payments for general hospital inpatient
27 services shall be limited to the Medicare deductible per spell
28 of illness. Medicaid shall make no payment toward coinsurance
29 for Medicare general hospital inpatient services.
30
31
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HB 1975, First Engrossed/ntc
1 4. Medicaid shall pay all deductibles and coinsurance
2 for Medicare emergency transportation services provided by
3 ambulances licensed pursuant to chapter 401.
4 (14) A provider of prescribed drugs shall be
5 reimbursed the least of the amount billed by the provider, the
6 provider's usual and customary charge, or the Medicaid maximum
7 allowable fee established by the agency, plus a dispensing
8 fee. The agency is directed to implement a variable dispensing
9 fee for payments for prescribed medicines while ensuring
10 continued access for Medicaid recipients. The variable
11 dispensing fee may be based upon, but not limited to, either
12 or both the volume of prescriptions dispensed by a specific
13 pharmacy provider, the volume of prescriptions dispensed to an
14 individual recipient, and dispensing of preferred-drug-list
15 products. The agency shall increase the pharmacy dispensing
16 fee authorized by statute and in the annual General
17 Appropriations Act by $0.50 for the dispensing of a Medicaid
18 preferred-drug-list product and reduce the pharmacy dispensing
19 fee by $0.50 for the dispensing of a Medicaid product that is
20 not included on the preferred-drug list. The agency is
21 authorized to limit reimbursement for prescribed medicine in
22 order to comply with any limitations or directions provided
23 for in the General Appropriations Act, which may include
24 implementing a prospective or concurrent utilization review
25 program.
26 (15) A provider of primary care case management
27 services rendered pursuant to a federally approved waiver
28 shall be reimbursed by payment of a fixed, prepaid monthly sum
29 for each Medicaid recipient enrolled with the provider.
30 (16) A provider of rural health clinic services and
31 federally qualified health center services shall be reimbursed
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HB 1975, First Engrossed/ntc
1 a rate per visit based on total reasonable costs of the
2 clinic, as determined by the agency in accordance with federal
3 regulations.
4 (17) A provider of targeted case management services
5 shall be reimbursed pursuant to an established fee, except
6 where the Federal Government requires a public provider be
7 reimbursed on the basis of average actual costs.
8 (18) Unless otherwise provided for in the General
9 Appropriations Act, a provider of transportation services
10 shall be reimbursed the lesser of the amount billed by the
11 provider or the Medicaid maximum allowable fee established by
12 the agency, except when the agency has entered into a direct
13 contract with the provider, or with a community transportation
14 coordinator, for the provision of an all-inclusive service, or
15 when services are provided pursuant to an agreement negotiated
16 between the agency and the provider. The agency, as provided
17 for in s. 427.0135, shall purchase transportation services
18 through the community coordinated transportation system, if
19 available, unless the agency determines a more cost-effective
20 method for Medicaid clients. Nothing in this subsection shall
21 be construed to limit or preclude the agency from contracting
22 for services using a prepaid capitation rate or from
23 establishing maximum fee schedules, individualized
24 reimbursement policies by provider type, negotiated fees,
25 prior authorization, competitive bidding, increased use of
26 mass transit, or any other mechanism that the agency considers
27 efficient and effective for the purchase of services on behalf
28 of Medicaid clients, including implementing a transportation
29 eligibility process. The agency shall not be required to
30 contract with any community transportation coordinator or
31 transportation operator that has been determined by the
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HB 1975, First Engrossed/ntc
1 agency, the Department of Legal Affairs Medicaid Fraud Control
2 Unit, or any other state or federal agency to have engaged in
3 any abusive or fraudulent billing activities. The agency is
4 authorized to competitively procure transportation services or
5 make other changes necessary to secure approval of federal
6 waivers needed to permit federal financing of Medicaid
7 transportation services at the service matching rate rather
8 than the administrative matching rate.
9 (19) County health department services may be
10 reimbursed a rate per visit based on total reasonable costs of
11 the clinic, as determined by the agency in accordance with
12 federal regulations under the authority of 42 C.F.R. s.
13 431.615.
14 (20) A renal dialysis facility that provides dialysis
15 services under s. 409.906(9) must be reimbursed the lesser of
16 the amount billed by the provider, the provider's usual and
17 customary charge, or the maximum allowable fee established by
18 the agency, whichever amount is less.
19 (21) The agency shall reimburse school districts which
20 certify the state match pursuant to ss. 236.0812 and 409.9071
21 for the federal portion of the school district's allowable
22 costs to deliver the services, based on the reimbursement
23 schedule. The school district shall determine the costs for
24 delivering services as authorized in ss. 236.0812 and 409.9071
25 for which the state match will be certified. Reimbursement of
26 school-based providers is contingent on such providers being
27 enrolled as Medicaid providers and meeting the qualifications
28 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
29 the federal Health Care Financing Administration. Speech
30 therapy providers who are certified through the Department of
31 Education pursuant to rule 6A-4.0176, Florida Administrative
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HB 1975, First Engrossed/ntc
1 Code, are eligible for reimbursement for services that are
2 provided on school premises. Any employee of the school
3 district who has been fingerprinted and has received a
4 criminal background check in accordance with Department of
5 Education rules and guidelines shall be exempt from any agency
6 requirements relating to criminal background checks.
7 (22) The agency shall request and implement Medicaid
8 waivers from the federal Health Care Financing Administration
9 to advance and treat a portion of the Medicaid nursing home
10 per diem as capital for creating and operating a
11 risk-retention group for self-insurance purposes, consistent
12 with federal and state laws and rules.
13 Section 13. Paragraph (b) of subsection (7) of section
14 409.910, Florida Statutes, is amended to read:
15 409.910 Responsibility for payments on behalf of
16 Medicaid-eligible persons when other parties are liable.--
17 (7) The agency shall recover the full amount of all
18 medical assistance provided by Medicaid on behalf of the
19 recipient to the full extent of third-party benefits.
20 (b) Upon receipt of any recovery or other collection
21 pursuant to this section, s. 409.913, or s. 409.920, the
22 agency shall distribute the amount collected as follows:
23 1. To itself and to any county that has responsibility
24 for certain items of care and service as mandated in s.
25 409.915, amounts an amount equal to a pro rata distribution of
26 the county's contribution and the state's state respective
27 Medicaid expenditures for the recipient plus any incentive
28 payment made in accordance with paragraph (14)(a). However, if
29 a county has been billed for its participation but has not
30 paid the amount due, the agency shall offset that amount and
31 notify the county of the amount of the offset. If the county
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HB 1975, First Engrossed/ntc
1 has divided its financial responsibility between the county
2 and a special taxing district or authority as contemplated in
3 s. 409.915(6), the county must proportionately divide any
4 refund or offset in accordance with the proration that it has
5 established.
6 2. To the Federal Government, the federal share of the
7 state Medicaid expenditures minus any incentive payment made
8 in accordance with paragraph (14)(a) and federal law, and
9 minus any other amount permitted by federal law to be
10 deducted.
11 3. To the recipient, after deducting any known amounts
12 owed to the agency for any related medical assistance or to
13 health care providers, any remaining amount. This amount shall
14 be treated as income or resources in determining eligibility
15 for Medicaid.
16
17 The provisions of this subsection do not apply to any proceeds
18 received by the state, or any agency thereof, pursuant to a
19 final order, judgment, or settlement agreement, in any matter
20 in which the state asserts claims brought on its own behalf,
21 and not as a subrogee of a recipient, or under other theories
22 of liability. The provisions of this subsection do not apply
23 to any proceeds received by the state, or an agency thereof,
24 pursuant to a final order, judgment, or settlement agreement,
25 in any matter in which the state asserted both claims as a
26 subrogee and additional claims, except as to those sums
27 specifically identified in the final order, judgment, or
28 settlement agreement as reimbursements to the recipient as
29 expenditures for the named recipient on the subrogation claim.
30 Section 14. Subsection (7) of section 409.9116,
31 Florida Statutes, is amended to read:
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HB 1975, First Engrossed/ntc
1 409.9116 Disproportionate share/financial assistance
2 program for rural hospitals.--In addition to the payments made
3 under s. 409.911, the Agency for Health Care Administration
4 shall administer a federally matched disproportionate share
5 program and a state-funded financial assistance program for
6 statutory rural hospitals. The agency shall make
7 disproportionate share payments to statutory rural hospitals
8 that qualify for such payments and financial assistance
9 payments to statutory rural hospitals that do not qualify for
10 disproportionate share payments. The disproportionate share
11 program payments shall be limited by and conform with federal
12 requirements. Funds shall be distributed quarterly in each
13 fiscal year for which an appropriation is made.
14 Notwithstanding the provisions of s. 409.915, counties are
15 exempt from contributing toward the cost of this special
16 reimbursement for hospitals serving a disproportionate share
17 of low-income patients.
18 (7) This section applies only to hospitals that were
19 defined as statutory rural hospitals, or their
20 successor-in-interest hospital, prior to July 1, 1999 1998.
21 Any additional hospital that is defined as a statutory rural
22 hospital, or its successor-in-interest hospital, on or after
23 July 1, 1999 1998, is not eligible for programs under this
24 section unless additional funds are appropriated each fiscal
25 year specifically to the rural hospital disproportionate share
26 and financial assistance programs in an amount necessary to
27 prevent any hospital, or its successor-in-interest hospital,
28 eligible for the programs prior to July 1, 1999 1998, from
29 incurring a reduction in payments because of the eligibility
30 of an additional hospital to participate in the programs. A
31 hospital, or its successor-in-interest hospital, which
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1 received funds pursuant to this section before July 1, 1999
2 1998, and which qualifies under s. 395.602(2)(e), shall be
3 included in the programs under this section and is not
4 required to seek additional appropriations under this
5 subsection.
6 Section 15. Paragraph (b) of subsection (3) and
7 paragraph (b) of subsection (13) of section 409.912, Florida
8 Statutes, are amended to read:
9 409.912 Cost-effective purchasing of health care.--The
10 agency shall purchase goods and services for Medicaid
11 recipients in the most cost-effective manner consistent with
12 the delivery of quality medical care. The agency shall
13 maximize the use of prepaid per capita and prepaid aggregate
14 fixed-sum basis services when appropriate and other
15 alternative service delivery and reimbursement methodologies,
16 including competitive bidding pursuant to s. 287.057, designed
17 to facilitate the cost-effective purchase of a case-managed
18 continuum of care. The agency shall also require providers to
19 minimize the exposure of recipients to the need for acute
20 inpatient, custodial, and other institutional care and the
21 inappropriate or unnecessary use of high-cost services. The
22 agency may establish prior authorization requirements for
23 certain populations of Medicaid beneficiaries, certain drug
24 classes, or particular drugs to prevent fraud, abuse, overuse,
25 and possible dangerous drug interactions. The Pharmaceutical
26 and Therapeutics Committee shall make recommendations to the
27 agency on drugs for which prior authorization is required. The
28 agency shall inform the Pharmaceutical and Therapeutics
29 Committee of its decisions regarding drugs subject to prior
30 authorization.
31 (3) The agency may contract with:
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1 (b) An entity that is providing comprehensive
2 behavioral health care services to certain Medicaid recipients
3 through a capitated, prepaid arrangement pursuant to the
4 federal waiver provided for by s. 409.905(5). Such an entity
5 must be licensed under chapter 624, chapter 636, or chapter
6 641 and must possess the clinical systems and operational
7 competence to manage risk and provide comprehensive behavioral
8 health care to Medicaid recipients. As used in this paragraph,
9 the term "comprehensive behavioral health care services" means
10 covered mental health and substance abuse treatment services
11 that are available to Medicaid recipients. The secretary of
12 the Department of Children and Family Services shall approve
13 provisions of procurements related to children in the
14 department's care or custody prior to enrolling such children
15 in a prepaid behavioral health plan. Any contract awarded
16 under this paragraph must be competitively procured. In
17 developing the behavioral health care prepaid plan procurement
18 document, the agency shall ensure that the procurement
19 document requires the contractor to develop and implement a
20 plan to ensure compliance with s. 394.4574 related to services
21 provided to residents of licensed assisted living facilities
22 that hold a limited mental health license. The agency must
23 ensure that Medicaid recipients have available the choice of
24 at least two managed care plans for their behavioral health
25 care services. To ensure unimpaired access to behavioral
26 health care services by Medicaid recipients, all contracts
27 issued pursuant to this paragraph shall require 80 percent of
28 the capitation paid to the managed care plan, including health
29 maintenance organizations, to be expended for the provision of
30 behavioral health care services. In the event the managed care
31 plan expends less than 80 percent of the capitation paid
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1 pursuant to this paragraph for the provision of behavioral
2 health care services, the difference shall be returned to the
3 agency. The agency shall provide the managed care plan with a
4 certification letter indicating the amount of capitation paid
5 during each calendar year for the provision of behavioral
6 health care services pursuant to this section. The agency may
7 reimburse for substance-abuse-treatment services on a
8 fee-for-service basis until the agency finds that adequate
9 funds are available for capitated, prepaid arrangements.
10 1. By January 1, 2001, the agency shall modify the
11 contracts with the entities providing comprehensive inpatient
12 and outpatient mental health care services to Medicaid
13 recipients in Hillsborough, Highlands, Hardee, Manatee, and
14 Polk Counties, to include substance-abuse-treatment services.
15 2. By December 31, 2001, the agency shall contract
16 with entities providing comprehensive behavioral health care
17 services to Medicaid recipients through capitated, prepaid
18 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
19 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
20 and Walton Counties. The agency may contract with entities
21 providing comprehensive behavioral health care services to
22 Medicaid recipients through capitated, prepaid arrangements in
23 Alachua County. The agency may determine if Sarasota County
24 shall be included as a separate catchment area or included in
25 any other agency geographic area.
26 3. Children residing in a Department of Juvenile
27 Justice residential program approved as a Medicaid behavioral
28 health overlay services provider shall not be included in a
29 behavioral health care prepaid health plan pursuant to this
30 paragraph.
31
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1 4. In converting to a prepaid system of delivery, the
2 agency shall in its procurement document require an entity
3 providing comprehensive behavioral health care services to
4 prevent the displacement of indigent care patients by
5 enrollees in the Medicaid prepaid health plan providing
6 behavioral health care services from facilities receiving
7 state funding to provide indigent behavioral health care, to
8 facilities licensed under chapter 395 which do not receive
9 state funding for indigent behavioral health care, or
10 reimburse the unsubsidized facility for the cost of behavioral
11 health care provided to the displaced indigent care patient.
12 5. Traditional community mental health providers under
13 contract with the Department of Children and Family Services
14 pursuant to part IV of chapter 394 and inpatient mental health
15 providers licensed pursuant to chapter 395 must be offered an
16 opportunity to accept or decline a contract to participate in
17 any provider network for prepaid behavioral health services.
18 (13)
19 (b) The responsibility of the agency under this
20 subsection shall include the development of capabilities to
21 identify actual and optimal practice patterns; patient and
22 provider educational initiatives; methods for determining
23 patient compliance with prescribed treatments; fraud, waste,
24 and abuse prevention and detection programs; and beneficiary
25 case management programs.
26 1. The practice pattern identification program shall
27 evaluate practitioner prescribing patterns based on national
28 and regional practice guidelines, comparing practitioners to
29 their peer groups. The agency and its Drug Utilization Review
30 Board shall consult with a panel of practicing health care
31 professionals consisting of the following: the Speaker of the
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1 House of Representatives and the President of the Senate shall
2 each appoint three physicians licensed under chapter 458 or
3 chapter 459; and the Governor shall appoint two pharmacists
4 licensed under chapter 465 and one dentist licensed under
5 chapter 466 who is an oral surgeon. Terms of the panel members
6 shall expire at the discretion of the appointing official. The
7 panel shall begin its work by August 1, 1999, regardless of
8 the number of appointments made by that date. The advisory
9 panel shall be responsible for evaluating treatment guidelines
10 and recommending ways to incorporate their use in the practice
11 pattern identification program. Practitioners who are
12 prescribing inappropriately or inefficiently, as determined by
13 the agency, may have their prescribing of certain drugs
14 subject to prior authorization.
15 2. The agency shall also develop educational
16 interventions designed to promote the proper use of
17 medications by providers and beneficiaries.
18 3. The agency shall implement a pharmacy fraud, waste,
19 and abuse initiative that may include a surety bond or letter
20 of credit requirement for participating pharmacies, enhanced
21 provider auditing practices, the use of additional fraud and
22 abuse software, recipient management programs for
23 beneficiaries inappropriately using their benefits, and other
24 steps that will eliminate provider and recipient fraud, waste,
25 and abuse. The initiative shall address enforcement efforts to
26 reduce the number and use of counterfeit prescriptions.
27 4. By September 30, 2002, the agency shall contract
28 with an entity in the state to implement a wireless handheld
29 clinical pharmacology drug information database for
30 high-prescribing practitioners, as determined by the agency.
31 The initiative shall be designed to enhance the agency's
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1 efforts to reduce fraud, abuse, and errors in the prescription
2 drug benefit program and to otherwise further the intent of
3 this paragraph.
4 5.4. The agency may apply for any federal waivers
5 needed to implement this paragraph.
6 Section 16. Paragraph (f) of subsection (2) of section
7 409.9122, Florida Statutes, as amended by section 11 of
8 chapter 2001-377, Laws of Florida, is amended to read:
9 409.9122 Mandatory Medicaid managed care enrollment;
10 programs and procedures.--
11 (2)
12 (f) When a Medicaid recipient does not choose a
13 managed care plan or MediPass provider, the agency shall
14 assign the Medicaid recipient to a managed care plan or
15 MediPass provider. Medicaid recipients who are subject to
16 mandatory assignment but who fail to make a choice shall be
17 assigned to managed care plans or provider service networks
18 until a proportional an equal enrollment of 45 50 percent in
19 MediPass and 55 50 percent in managed care plans is achieved.
20 Once the 45/55 proportional equal enrollment is achieved, the
21 assignments shall be divided in order to maintain an equal
22 enrollment in MediPass and managed care plans. Thereafter,
23 assignment of Medicaid recipients who fail to make a choice
24 shall be based proportionally on the preferences of recipients
25 who have made a choice in the previous period. Such
26 proportions shall be revised at least quarterly to reflect an
27 update of the preferences of Medicaid recipients. The agency
28 shall also disproportionately assign Medicaid-eligible
29 children in families who are required to but have failed to
30 make a choice of managed care plan or MediPass for their child
31 and who are to be assigned to the MediPass program to
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1 children's networks as described in s. 409.912(3)(g) and where
2 available. The disproportionate assignment of children to
3 children's networks shall be made until the agency has
4 determined that the children's networks have sufficient
5 numbers to be economically operated. For purposes of this
6 paragraph, when referring to assignment, the term "managed
7 care plans" includes exclusive provider organizations,
8 provider service networks, minority physician networks, and
9 pediatric emergency department diversion programs authorized
10 by this chapter or the General Appropriations Act. When making
11 assignments, the agency shall take into account the following
12 criteria:
13 1. A managed care plan has sufficient network capacity
14 to meet the need of members.
15 2. The managed care plan or MediPass has previously
16 enrolled the recipient as a member, or one of the managed care
17 plan's primary care providers or MediPass providers has
18 previously provided health care to the recipient.
19 3. The agency has knowledge that the member has
20 previously expressed a preference for a particular managed
21 care plan or MediPass provider as indicated by Medicaid
22 fee-for-service claims data, but has failed to make a choice.
23 4. The managed care plan's or MediPass primary care
24 providers are geographically accessible to the recipient's
25 residence.
26 Section 17. Section 409.913, Florida Statutes, as
27 amended by section 12 of chapter 2001-377, Laws of Florida, is
28 amended to read:
29 409.913 Oversight of the integrity of the Medicaid
30 program.--The agency shall operate a program to oversee the
31 activities of Florida Medicaid recipients, and providers and
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1 their representatives, to ensure that fraudulent and abusive
2 behavior and neglect of recipients occur to the minimum extent
3 possible, and to recover overpayments and impose sanctions as
4 appropriate. Beginning January 1, 2003, and each year
5 thereafter, the agency and the Medicaid Fraud Control Unit of
6 the Department of Legal Affairs shall submit a joint report to
7 the Legislature documenting the effectiveness of the state's
8 efforts to control Medicaid fraud and abuse and to recover
9 Medicaid overpayments during the previous fiscal year. The
10 report must describe the number of cases opened and
11 investigated each year; the sources of the cases opened; the
12 disposition of the cases closed each year; the amount of
13 overpayments alleged in preliminary and final audit letters;
14 the number and amount of fines or penalties imposed; any
15 reductions in overpayment amounts negotiated in settlement
16 agreements or by other means; the amount of final agency
17 determinations of overpayments; the amount deducted from
18 federal claiming as a result of overpayments; the amount of
19 overpayments recovered each year; the amount of cost of
20 investigation recovered each year; the average length of time
21 to collect from the time the case was opened until the
22 overpayment is paid in full; the amount determined as
23 uncollectible and the portion of the uncollectible amount
24 subsequently reclaimed from the Federal Government; the number
25 of providers, by type, that are terminated from participation
26 in the Medicaid program as a result of fraud and abuse; and
27 all costs associated with discovering and prosecuting cases of
28 Medicaid overpayments and making recoveries in such cases. The
29 report must also document actions taken to prevent
30 overpayments and the number of providers prevented from
31 enrolling in or reenrolling in the Medicaid program as a
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1 result of documented Medicaid fraud and abuse and must
2 recommend changes necessary to prevent or recover
3 overpayments. For the 2001-2002 fiscal year, the agency shall
4 prepare a report that contains as much of this information as
5 is available to it.
6 (1) For the purposes of this section, the term:
7 (a) "Abuse" means:
8 1. Provider practices that are inconsistent with
9 generally accepted business or medical practices and that
10 result in an unnecessary cost to the Medicaid program or in
11 reimbursement for goods or services that are not medically
12 necessary or that fail to meet professionally recognized
13 standards for health care.
14 2. Recipient practices that result in unnecessary cost
15 to the Medicaid program.
16 (b) "Complaint" means an allegation that fraud, abuse,
17 or an overpayment has occurred.
18 (c)(b) "Fraud" means an intentional deception or
19 misrepresentation made by a person with the knowledge that the
20 deception results in unauthorized benefit to herself or
21 himself or another person. The term includes any act that
22 constitutes fraud under applicable federal or state law.
23 (d)(c) "Medical necessity" or "medically necessary"
24 means any goods or services necessary to palliate the effects
25 of a terminal condition, or to prevent, diagnose, correct,
26 cure, alleviate, or preclude deterioration of a condition that
27 threatens life, causes pain or suffering, or results in
28 illness or infirmity, which goods or services are provided in
29 accordance with generally accepted standards of medical
30 practice. For purposes of determining Medicaid reimbursement,
31 the agency is the final arbiter of medical necessity.
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1 Determinations of medical necessity must be made by a licensed
2 physician employed by or under contract with the agency and
3 must be based upon information available at the time the goods
4 or services are provided.
5 (e)(d) "Overpayment" includes any amount that is not
6 authorized to be paid by the Medicaid program whether paid as
7 a result of inaccurate or improper cost reporting, improper
8 claiming, unacceptable practices, fraud, abuse, or mistake.
9 (f)(e) "Person" means any natural person, corporation,
10 partnership, association, clinic, group, or other entity,
11 whether or not such person is enrolled in the Medicaid program
12 or is a provider of health care.
13 (2) The agency shall conduct, or cause to be conducted
14 by contract or otherwise, reviews, investigations, analyses,
15 audits, or any combination thereof, to determine possible
16 fraud, abuse, overpayment, or recipient neglect in the
17 Medicaid program and shall report the findings of any
18 overpayments in audit reports as appropriate.
19 (3) The agency may conduct, or may contract for,
20 prepayment review of provider claims to ensure cost-effective
21 purchasing, billing, and provision of care to Medicaid
22 recipients. Such prepayment reviews may be conducted as
23 determined appropriate by the agency, without any suspicion or
24 allegation of fraud, abuse, or neglect.
25 (4) Any suspected criminal violation identified by the
26 agency must be referred to the Medicaid Fraud Control Unit of
27 the Office of the Attorney General for investigation. The
28 agency and the Attorney General shall enter into a memorandum
29 of understanding, which must include, but need not be limited
30 to, a protocol for regularly sharing information and
31 coordinating casework. The protocol must establish a
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1 procedure for the referral by the agency of cases involving
2 suspected Medicaid fraud to the Medicaid Fraud Control Unit
3 for investigation, and the return to the agency of those cases
4 where investigation determines that administrative action by
5 the agency is appropriate. Offices of the Medicaid program
6 integrity program and the Medicaid Fraud Control Unit of the
7 Department of Legal Affairs shall, to the extent possible, be
8 colocated. The agency and the Department of Legal Affairs
9 shall periodically conduct joint training and other joint
10 activities designed to increase communication and coordination
11 in recovering overpayments.
12 (5) A Medicaid provider is subject to having goods and
13 services that are paid for by the Medicaid program reviewed by
14 an appropriate peer-review organization designated by the
15 agency. The written findings of the applicable peer-review
16 organization are admissible in any court or administrative
17 proceeding as evidence of medical necessity or the lack
18 thereof.
19 (6) Any notice required to be given to a provider
20 under this section is presumed to be sufficient notice if sent
21 to the address last shown on the provider enrollment file. It
22 is the responsibility of the provider to furnish and keep the
23 agency informed of the provider's current address. United
24 States Postal Service proof of mailing or certified or
25 registered mailing of such notice to the provider at the
26 address shown on the provider enrollment file constitutes
27 sufficient proof of notice. Any notice required to be given to
28 the agency by this section must be sent to the agency at an
29 address designated by rule.
30 (7) When presenting a claim for payment under the
31 Medicaid program, a provider has an affirmative duty to
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1 supervise the provision of, and be responsible for, goods and
2 services claimed to have been provided, to supervise and be
3 responsible for preparation and submission of the claim, and
4 to present a claim that is true and accurate and that is for
5 goods and services that:
6 (a) Have actually been furnished to the recipient by
7 the provider prior to submitting the claim.
8 (b) Are Medicaid-covered goods or services that are
9 medically necessary.
10 (c) Are of a quality comparable to those furnished to
11 the general public by the provider's peers.
12 (d) Have not been billed in whole or in part to a
13 recipient or a recipient's responsible party, except for such
14 copayments, coinsurance, or deductibles as are authorized by
15 the agency.
16 (e) Are provided in accord with applicable provisions
17 of all Medicaid rules, regulations, handbooks, and policies
18 and in accordance with federal, state, and local law.
19 (f) Are documented by records made at the time the
20 goods or services were provided, demonstrating the medical
21 necessity for the goods or services rendered. Medicaid goods
22 or services are excessive or not medically necessary unless
23 both the medical basis and the specific need for them are
24 fully and properly documented in the recipient's medical
25 record.
26 (8) A Medicaid provider shall retain medical,
27 professional, financial, and business records pertaining to
28 services and goods furnished to a Medicaid recipient and
29 billed to Medicaid for a period of 5 years after the date of
30 furnishing such services or goods. The agency may investigate,
31 review, or analyze such records, which must be made available
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1 during normal business hours. However, 24-hour notice must be
2 provided if patient treatment would be disrupted. The provider
3 is responsible for furnishing to the agency, and keeping the
4 agency informed of the location of, the provider's
5 Medicaid-related records. The authority of the agency to
6 obtain Medicaid-related records from a provider is neither
7 curtailed nor limited during a period of litigation between
8 the agency and the provider.
9 (9) Payments for the services of billing agents or
10 persons participating in the preparation of a Medicaid claim
11 shall not be based on amounts for which they bill nor based on
12 the amount a provider receives from the Medicaid program.
13 (10) The agency may require repayment for
14 inappropriate, medically unnecessary, or excessive goods or
15 services from the person furnishing them, the person under
16 whose supervision they were furnished, or the person causing
17 them to be furnished.
18 (11) The complaint and all information obtained
19 pursuant to an investigation of a Medicaid provider, or the
20 authorized representative or agent of a provider, relating to
21 an allegation of fraud, abuse, or neglect are confidential and
22 exempt from the provisions of s. 119.07(1):
23 (a) Until the agency takes final agency action with
24 respect to the provider and requires repayment of any
25 overpayment, or imposes an administrative sanction;
26 (b) Until the Attorney General refers the case for
27 criminal prosecution;
28 (c) Until 10 days after the complaint is determined
29 without merit; or
30 (d) At all times if the complaint or information is
31 otherwise protected by law.
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1 (12) The agency may terminate participation of a
2 Medicaid provider in the Medicaid program and may seek civil
3 remedies or impose other administrative sanctions against a
4 Medicaid provider, if the provider has been:
5 (a) Convicted of a criminal offense related to the
6 delivery of any health care goods or services, including the
7 performance of management or administrative functions relating
8 to the delivery of health care goods or services;
9 (b) Convicted of a criminal offense under federal law
10 or the law of any state relating to the practice of the
11 provider's profession; or
12 (c) Found by a court of competent jurisdiction to have
13 neglected or physically abused a patient in connection with
14 the delivery of health care goods or services.
15 (13) If the provider has been suspended or terminated
16 from participation in the Medicaid program or the Medicare
17 program by the Federal Government or any state, the agency
18 must immediately suspend or terminate, as appropriate, the
19 provider's participation in the Florida Medicaid program for a
20 period no less than that imposed by the Federal Government or
21 any other state, and may not enroll such provider in the
22 Florida Medicaid program while such foreign suspension or
23 termination remains in effect. This sanction is in addition
24 to all other remedies provided by law.
25 (14) The agency may seek any remedy provided by law,
26 including, but not limited to, the remedies provided in
27 subsections (12) and (15) and s. 812.035, if:
28 (a) The provider's license has not been renewed, or
29 has been revoked, suspended, or terminated, for cause, by the
30 licensing agency of any state;
31
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1 (b) The provider has failed to make available or has
2 refused access to Medicaid-related records to an auditor,
3 investigator, or other authorized employee or agent of the
4 agency, the Attorney General, a state attorney, or the Federal
5 Government;
6 (c) The provider has not furnished or has failed to
7 make available such Medicaid-related records as the agency has
8 found necessary to determine whether Medicaid payments are or
9 were due and the amounts thereof;
10 (d) The provider has failed to maintain medical
11 records made at the time of service, or prior to service if
12 prior authorization is required, demonstrating the necessity
13 and appropriateness of the goods or services rendered;
14 (e) The provider is not in compliance with provisions
15 of Medicaid provider publications that have been adopted by
16 reference as rules in the Florida Administrative Code; with
17 provisions of state or federal laws, rules, or regulations;
18 with provisions of the provider agreement between the agency
19 and the provider; or with certifications found on claim forms
20 or on transmittal forms for electronically submitted claims
21 that are submitted by the provider or authorized
22 representative, as such provisions apply to the Medicaid
23 program;
24 (f) The provider or person who ordered or prescribed
25 the care, services, or supplies has furnished, or ordered the
26 furnishing of, goods or services to a recipient which are
27 inappropriate, unnecessary, excessive, or harmful to the
28 recipient or are of inferior quality;
29 (g) The provider has demonstrated a pattern of failure
30 to provide goods or services that are medically necessary;
31
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1 (h) The provider or an authorized representative of
2 the provider, or a person who ordered or prescribed the goods
3 or services, has submitted or caused to be submitted false or
4 a pattern of erroneous Medicaid claims that have resulted in
5 overpayments to a provider or that exceed those to which the
6 provider was entitled under the Medicaid program;
7 (i) The provider or an authorized representative of
8 the provider, or a person who has ordered or prescribed the
9 goods or services, has submitted or caused to be submitted a
10 Medicaid provider enrollment application, a request for prior
11 authorization for Medicaid services, a drug exception request,
12 or a Medicaid cost report that contains materially false or
13 incorrect information;
14 (j) The provider or an authorized representative of
15 the provider has collected from or billed a recipient or a
16 recipient's responsible party improperly for amounts that
17 should not have been so collected or billed by reason of the
18 provider's billing the Medicaid program for the same service;
19 (k) The provider or an authorized representative of
20 the provider has included in a cost report costs that are not
21 allowable under a Florida Title XIX reimbursement plan, after
22 the provider or authorized representative had been advised in
23 an audit exit conference or audit report that the costs were
24 not allowable;
25 (l) The provider is charged by information or
26 indictment with fraudulent billing practices. The sanction
27 applied for this reason is limited to suspension of the
28 provider's participation in the Medicaid program for the
29 duration of the indictment unless the provider is found guilty
30 pursuant to the information or indictment;
31
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1 (m) The provider or a person who has ordered, or
2 prescribed the goods or services is found liable for negligent
3 practice resulting in death or injury to the provider's
4 patient;
5 (n) The provider fails to demonstrate that it had
6 available during a specific audit or review period sufficient
7 quantities of goods, or sufficient time in the case of
8 services, to support the provider's billings to the Medicaid
9 program;
10 (o) The provider has failed to comply with the notice
11 and reporting requirements of s. 409.907; or
12 (p) The agency has received reliable information of
13 patient abuse or neglect or of any act prohibited by s.
14 409.920;.
15 (q) The provider has failed to comply with an
16 agreed-upon repayment schedule; or
17 (r) The provider has failed to timely file such
18 Medicaid cost reports as the agency considers necessary to set
19 or adjust payment rates.
20 (15) The agency shall may impose any of the following
21 sanctions or disincentives on a provider or a person for any
22 of the acts described in subsection (14):
23 (a) Suspension for a specific period of time of not
24 more than 1 year.
25 (b) Termination for a specific period of time of from
26 more than 1 year to 20 years.
27 (c) Imposition of a fine of up to $5,000 for each
28 violation. Each day that an ongoing violation continues, such
29 as refusing to furnish Medicaid-related records or refusing
30 access to records, is considered, for the purposes of this
31 section, to be a separate violation. Each instance of
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1 improper billing of a Medicaid recipient; each instance of
2 including an unallowable cost on a hospital or nursing home
3 Medicaid cost report after the provider or authorized
4 representative has been advised in an audit exit conference or
5 previous audit report of the cost unallowability; each
6 instance of furnishing a Medicaid recipient goods or
7 professional services that are inappropriate or of inferior
8 quality as determined by competent peer judgment; each
9 instance of knowingly submitting a materially false or
10 erroneous Medicaid provider enrollment application, request
11 for prior authorization for Medicaid services, drug exception
12 request, or cost report; each instance of inappropriate
13 prescribing of drugs for a Medicaid recipient as determined by
14 competent peer judgment; and each false or erroneous Medicaid
15 claim leading to an overpayment to a provider is considered,
16 for the purposes of this section, to be a separate violation.
17 (d) Immediate suspension, if the agency has received
18 information of patient abuse or neglect or of any act
19 prohibited by s. 409.920. Upon suspension, the agency must
20 issue an immediate final order under s. 120.569(2)(n).
21 (e) A fine, not to exceed $10,000, for a violation of
22 paragraph (14)(i).
23 (f) Imposition of liens against provider assets,
24 including, but not limited to, financial assets and real
25 property, not to exceed the amount of fines or recoveries
26 sought, upon entry of an order determining that such moneys
27 are due or recoverable.
28 (g) Prepayment reviews of claims for a specified
29 period of time.
30 (h) Comprehensive followup reviews of providers every
31 6 months to ensure that they are billing Medicaid correctly.
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1 (i) Corrective action plans that would remain in
2 effect for providers for up to 3 years and that would be
3 monitored by the agency every 6 months while in effect.
4 (j)(g) Other remedies as permitted by law to effect
5 the recovery of a fine or overpayment.
6
7 The Secretary of Health Care Administration may make a
8 determination that imposition of a sanction or disincentive is
9 not in the best interest of the Medicaid program, in which
10 case a sanction or disincentive shall not be imposed.
11 (16) In determining the appropriate administrative
12 sanction to be applied, or the duration of any suspension or
13 termination, the agency shall consider:
14 (a) The seriousness and extent of the violation or
15 violations.
16 (b) Any prior history of violations by the provider
17 relating to the delivery of health care programs which
18 resulted in either a criminal conviction or in administrative
19 sanction or penalty.
20 (c) Evidence of continued violation within the
21 provider's management control of Medicaid statutes, rules,
22 regulations, or policies after written notification to the
23 provider of improper practice or instance of violation.
24 (d) The effect, if any, on the quality of medical care
25 provided to Medicaid recipients as a result of the acts of the
26 provider.
27 (e) Any action by a licensing agency respecting the
28 provider in any state in which the provider operates or has
29 operated.
30
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1 (f) The apparent impact on access by recipients to
2 Medicaid services if the provider is suspended or terminated,
3 in the best judgment of the agency.
4
5 The agency shall document the basis for all sanctioning
6 actions and recommendations.
7 (17) The agency may take action to sanction, suspend,
8 or terminate a particular provider working for a group
9 provider, and may suspend or terminate Medicaid participation
10 at a specific location, rather than or in addition to taking
11 action against an entire group.
12 (18) The agency shall establish a process for
13 conducting followup reviews of a sampling of providers who
14 have a history of overpayment under the Medicaid program.
15 This process must consider the magnitude of previous fraud or
16 abuse and the potential effect of continued fraud or abuse on
17 Medicaid costs.
18 (19) In making a determination of overpayment to a
19 provider, the agency must use accepted and valid auditing,
20 accounting, analytical, statistical, or peer-review methods,
21 or combinations thereof. Appropriate statistical methods may
22 include, but are not limited to, sampling and extension to the
23 population, parametric and nonparametric statistics, tests of
24 hypotheses, and other generally accepted statistical methods.
25 Appropriate analytical methods may include, but are not
26 limited to, reviews to determine variances between the
27 quantities of products that a provider had on hand and
28 available to be purveyed to Medicaid recipients during the
29 review period and the quantities of the same products paid for
30 by the Medicaid program for the same period, taking into
31 appropriate consideration sales of the same products to
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1 non-Medicaid customers during the same period. In meeting its
2 burden of proof in any administrative or court proceeding, the
3 agency may introduce the results of such statistical methods
4 as evidence of overpayment.
5 (20) When making a determination that an overpayment
6 has occurred, the agency shall prepare and issue an audit
7 report to the provider showing the calculation of
8 overpayments.
9 (21) The audit report, supported by agency work
10 papers, showing an overpayment to a provider constitutes
11 evidence of the overpayment. A provider may not present or
12 elicit testimony, either on direct examination or
13 cross-examination in any court or administrative proceeding,
14 regarding the purchase or acquisition by any means of drugs,
15 goods, or supplies; sales or divestment by any means of drugs,
16 goods, or supplies; or inventory of drugs, goods, or supplies,
17 unless such acquisition, sales, divestment, or inventory is
18 documented by written invoices, written inventory records, or
19 other competent written documentary evidence maintained in the
20 normal course of the provider's business. Notwithstanding the
21 applicable rules of discovery, all documentation that will be
22 offered as evidence at an administrative hearing on a Medicaid
23 overpayment must be exchanged by all parties at least 14 days
24 before the administrative hearing or must be excluded from
25 consideration.
26 (22)(a) In an audit or investigation of a violation
27 committed by a provider which is conducted pursuant to this
28 section, the agency is entitled to recover all investigative,
29 legal, and expert witness costs if the agency's findings were
30 not contested by the provider or, if contested, the agency
31 ultimately prevailed.
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1 (b) The agency has the burden of documenting the
2 costs, which include salaries and employee benefits and
3 out-of-pocket expenses. The amount of costs that may be
4 recovered must be reasonable in relation to the seriousness of
5 the violation and must be set taking into consideration the
6 financial resources, earning ability, and needs of the
7 provider, who has the burden of demonstrating such factors.
8 (c) The provider may pay the costs over a period to be
9 determined by the agency if the agency determines that an
10 extreme hardship would result to the provider from immediate
11 full payment. Any default in payment of costs may be
12 collected by any means authorized by law.
13 (23) If the agency imposes an administrative sanction
14 under this section upon any provider or other person who is
15 regulated by another state entity, the agency shall notify
16 that other entity of the imposition of the sanction. Such
17 notification must include the provider's or person's name and
18 license number and the specific reasons for sanction.
19 (24)(a) The agency may withhold Medicaid payments, in
20 whole or in part, to a provider upon receipt of reliable
21 evidence that the circumstances giving rise to the need for a
22 withholding of payments involve fraud, willful
23 misrepresentation, or abuse under the Medicaid program, or a
24 crime committed while rendering goods or services to Medicaid
25 recipients, pending completion of legal proceedings. If it is
26 determined that fraud, willful misrepresentation, abuse, or a
27 crime did not occur, the payments withheld must be paid to the
28 provider within 14 days after such determination with interest
29 at the rate of 10 percent a year. Any money withheld in
30 accordance with this paragraph shall be placed in a suspended
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1 account, readily accessible to the agency, so that any payment
2 ultimately due the provider shall be made within 14 days.
3 (b) Overpayments owed to the agency bear interest at
4 the rate of 10 percent per year from the date of determination
5 of the overpayment by the agency, and payment arrangements
6 must be made at the conclusion of legal proceedings. A
7 provider who does not enter into or adhere to an agreed-upon
8 repayment schedule may be terminated by the agency for
9 nonpayment or partial payment.
10 (c) The agency, upon entry of a final agency order, a
11 judgment or order of a court of competent jurisdiction, or a
12 stipulation or settlement, may collect the moneys owed by all
13 means allowable by law, including, but not limited to,
14 notifying any fiscal intermediary of Medicare benefits that
15 the state has a superior right of payment. Upon receipt of
16 such written notification, the Medicare fiscal intermediary
17 shall remit to the state the sum claimed.
18 (25) The agency may impose administrative sanctions
19 against a Medicaid recipient, or the agency may seek any other
20 remedy provided by law, including, but not limited to, the
21 remedies provided in s. 812.035, if the agency finds that a
22 recipient has engaged in solicitation in violation of s.
23 409.920 or that the recipient has otherwise abused the
24 Medicaid program.
25 (26) When the Agency for Health Care Administration
26 has made a probable cause determination and alleged that an
27 overpayment to a Medicaid provider has occurred, the agency,
28 after notice to the provider, may:
29 (a) Withhold, and continue to withhold during the
30 pendency of an administrative hearing pursuant to chapter 120,
31 any medical assistance reimbursement payments until such time
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1 as the overpayment is recovered, unless within 30 days after
2 receiving notice thereof the provider:
3 1. Makes repayment in full; or
4 2. Establishes a repayment plan that is satisfactory
5 to the Agency for Health Care Administration.
6 (b) Withhold, and continue to withhold during the
7 pendency of an administrative hearing pursuant to chapter 120,
8 medical assistance reimbursement payments if the terms of a
9 repayment plan are not adhered to by the provider.
10
11 If a provider requests an administrative hearing pursuant to
12 chapter 120, such hearing must be conducted within 90 days
13 following receipt by the provider of the final audit report,
14 absent exceptionally good cause shown as determined by the
15 administrative law judge or hearing officer. Upon issuance of
16 a final order, the balance outstanding of the amount
17 determined to constitute the overpayment shall become due. Any
18 withholding of payments by the Agency for Health Care
19 Administration pursuant to this section shall be limited so
20 that the monthly medical assistance payment is not reduced by
21 more than 10 percent.
22 (27) Venue for all Medicaid program integrity
23 overpayment cases shall lie in Leon County, at the discretion
24 of the agency.
25 (28) Notwithstanding other provisions of law, the
26 agency and the Medicaid Fraud Control Unit of the Department
27 of Legal Affairs may review a provider's non-Medicaid-related
28 records in order to determine the total output of a provider's
29 practice to reconcile quantities of goods or services billed
30 to Medicaid against quantities of goods or services used in
31 the provider's total practice.
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1 (29) The agency may terminate a provider's
2 participation in the Medicaid program if the provider fails to
3 reimburse an overpayment that has been determined by final
4 order within 35 days after the date of the final order, unless
5 the provider and the agency have entered into a repayment
6 agreement. If the final order is overturned on appeal, the
7 provider shall be reinstated.
8 (30) If a provider requests an administrative hearing
9 pursuant to chapter 120, such hearing must be conducted within
10 90 days following assignment of an administrative law judge,
11 absent exceptionally good cause shown as determined by the
12 administrative law judge or hearing officer. Upon issuance of
13 a final order, the outstanding balance of the amount
14 determined to constitute the overpayment shall become due. If
15 a provider fails to make payments in full, fails to enter into
16 a satisfactory repayment plan, or fails to comply with the
17 terms of a repayment plan or settlement agreement, the agency
18 may withhold all medical assistance reimbursement payments
19 until the amount due is paid in full.
20 (31) Duly authorized agents and employees of the
21 agency and the Medicaid Fraud Control Unit of the Department
22 of Legal Affairs shall have the power to inspect, at all
23 reasonable hours and upon proper notice, the records of any
24 pharmacy, wholesale establishment, or manufacturer, or any
25 other place in the state in which drugs and medical supplies
26 are manufactured, packed, packaged, made, stored, sold, or
27 kept for sale, for the purpose of verifying the amount of
28 drugs and medical supplies ordered, delivered, or purchased by
29 a provider.
30 Section 18. Subsection (2) of section 409.915, Florida
31 Statutes, is amended to read:
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1 409.915 County contributions to Medicaid.--Although
2 the state is responsible for the full portion of the state
3 share of the matching funds required for the Medicaid program,
4 in order to acquire a certain portion of these funds, the
5 state shall charge the counties for certain items of care and
6 service as provided in this section.
7 (2) A county's participation must be 35 percent of the
8 total cost, or the applicable discounted cost paid by the
9 state for Medicaid recipients enrolled in health maintenance
10 organizations or prepaid health plans, of providing the items
11 listed in subsection (1), except that the payments for items
12 listed in paragraph (1)(b) may not exceed $140 $55 per month
13 per person.
14 Section 19. Subsections (7) and (8) of section
15 409.920, Florida Statutes, are amended to read:
16 409.920 Medicaid provider fraud.--
17 (7) The Attorney General shall conduct a statewide
18 program of Medicaid fraud control. To accomplish this purpose,
19 the Attorney General shall:
20 (a) Investigate the possible criminal violation of any
21 applicable state law pertaining to fraud in the administration
22 of the Medicaid program, in the provision of medical
23 assistance, or in the activities of providers of health care
24 under the Medicaid program.
25 (b) Investigate the alleged abuse or neglect of
26 patients in health care facilities receiving payments under
27 the Medicaid program, in coordination with the agency.
28 (c) Investigate the alleged misappropriation of
29 patients' private funds in health care facilities receiving
30 payments under the Medicaid program.
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1 (d) Refer to the Office of Statewide Prosecution or
2 the appropriate state attorney all violations indicating a
3 substantial potential for criminal prosecution.
4 (e) Refer to the agency all suspected abusive
5 activities not of a criminal or fraudulent nature.
6 (f) Refer to the agency for collection each instance
7 of overpayment to a provider of health care under the Medicaid
8 program which is discovered during the course of an
9 investigation.
10 (f)(g) Safeguard the privacy rights of all individuals
11 and provide safeguards to prevent the use of patient medical
12 records for any reason beyond the scope of a specific
13 investigation for fraud or abuse, or both, without the
14 patient's written consent.
15 (g) Publicize to state employees and the public the
16 ability of persons to bring suit under the provisions of the
17 Florida False Claims Act and the potential for the persons
18 bringing a civil action under the Florida False Claims Act to
19 obtain a monetary award.
20 (8) In carrying out the duties and responsibilities
21 under this section subsection, the Attorney General may:
22 (a) Enter upon the premises of any health care
23 provider, excluding a physician, participating in the Medicaid
24 program to examine all accounts and records that may, in any
25 manner, be relevant in determining the existence of fraud in
26 the Medicaid program, to investigate alleged abuse or neglect
27 of patients, or to investigate alleged misappropriation of
28 patients' private funds. A participating physician is required
29 to make available any accounts or records that may, in any
30 manner, be relevant in determining the existence of fraud in
31 the Medicaid program. The accounts or records of a
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1 non-Medicaid patient may not be reviewed by, or turned over
2 to, the Attorney General without the patient's written
3 consent.
4 (b) Subpoena witnesses or materials, including medical
5 records relating to Medicaid recipients, within or outside the
6 state and, through any duly designated employee, administer
7 oaths and affirmations and collect evidence for possible use
8 in either civil or criminal judicial proceedings.
9 (c) Request and receive the assistance of any state
10 attorney or law enforcement agency in the investigation and
11 prosecution of any violation of this section.
12 (d) Seek any civil remedy provided by law, including,
13 but not limited to, the remedies provided in ss.
14 68.081-68.092, s. 812.035, and this chapter.
15 (e) Refer to the agency for collection each instance
16 of overpayment to a provider of health care under the Medicaid
17 program which is discovered during the course of an
18 investigation.
19 Section 20. Effective July 1, 2002, subsection (1) and
20 paragraph (b) of subsection (4) of section 624.91, Florida
21 Statutes, as amended by section 20 of chapter 2001-377, Laws
22 of Florida, are amended to read:
23 624.91 The Florida Healthy Kids Corporation Act.--
24 (1) SHORT TITLE.--Sections 624.91-624.915 This section
25 may be cited as the "William G. 'Doc' Myers Healthy Kids
26 Corporation Act."
27 (4) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
28 (b) The Florida Healthy Kids Corporation shall phase
29 in a program to:
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1 1. Organize school children groups to facilitate the
2 provision of comprehensive health insurance coverage to
3 children;
4 2. Arrange for the collection of any family, local
5 contributions, or employer payment or premium, in an amount to
6 be determined by the board of directors, to provide for
7 payment of premiums for comprehensive insurance coverage and
8 for the actual or estimated administrative expenses;
9 3. Establish the administrative and accounting
10 procedures for the operation of the corporation;
11 4. Establish, with consultation from appropriate
12 professional organizations, standards for preventive health
13 services and providers and comprehensive insurance benefits
14 appropriate to children; provided that such standards for
15 rural areas shall not limit primary care providers to
16 board-certified pediatricians;
17 5. Establish eligibility criteria which children must
18 meet in order to participate in the program;
19 6. Establish procedures under which applicants to and
20 participants in the program may have grievances reviewed by an
21 impartial body and reported to the board of directors of the
22 corporation;
23 7. Establish participation criteria and, if
24 appropriate, contract with an authorized insurer, health
25 maintenance organization, or insurance administrator to
26 provide administrative services to the corporation;
27 8. Establish enrollment criteria which shall include
28 penalties or waiting periods of not fewer than 60 days for
29 reinstatement of coverage upon voluntary cancellation for
30 nonpayment of family premiums;
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1 9. If a space is available, establish a special open
2 enrollment period of 30 days' duration for any child who is
3 enrolled in Medicaid or Medikids if such child loses Medicaid
4 or Medikids eligibility and becomes eligible for the Florida
5 Healthy Kids program;
6 10. Contract with authorized insurers or any provider
7 of health care services, meeting standards established by the
8 corporation, for the provision of comprehensive insurance
9 coverage to participants. Such standards shall include
10 criteria under which the corporation may contract with more
11 than one provider of health care services in program sites.
12 Health plans shall be selected through a competitive bid
13 process. The selection of health plans shall be based
14 primarily on quality criteria established by the board. The
15 health plan selection criteria and scoring system, and the
16 scoring results, shall be available upon request for
17 inspection after the bids have been awarded;
18 11. Develop and implement a plan to publicize the
19 Florida Healthy Kids Corporation, the eligibility requirements
20 of the program, and the procedures for enrollment in the
21 program and to maintain public awareness of the corporation
22 and the program;
23 12. Secure staff necessary to properly administer the
24 corporation. Staff costs shall be funded from state and local
25 matching funds and such other private or public funds as
26 become available. The board of directors shall determine the
27 number of staff members necessary to administer the
28 corporation;
29 13. As appropriate, enter into contracts with local
30 school boards or other agencies to provide onsite information,
31
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1 enrollment, and other services necessary to the operation of
2 the corporation;
3 14. Provide a report on an annual basis to the
4 Governor, Insurance Commissioner, Commissioner of Education,
5 Senate President, Speaker of the House of Representatives, and
6 Minority Leaders of the Senate and the House of
7 Representatives;
8 15. Annually determine the local match requirements
9 for each county under the formulas and procedure provided in
10 s. 624.915 Each fiscal year, establish a maximum number of
11 participants by county, on a statewide basis, who may enroll
12 in the program without the benefit of local matching funds.
13 Thereafter, the corporation may establish local matching
14 requirements for supplemental participation in the program.
15 The corporation may vary local matching requirements and
16 enrollment by county depending on factors which may influence
17 the generation of local match, including, but not limited to,
18 population density, per capita income, existing local tax
19 effort, and other factors. The corporation also may accept
20 in-kind match in lieu of cash for the local match requirement
21 to the extent allowed by Title XXI of the Social Security Act;
22 and
23 16. Establish eligibility criteria, premium and
24 cost-sharing requirements, and benefit packages which conform
25 to the provisions of the Florida Kidcare program, as created
26 in ss. 409.810-409.820.; and
27 17. Notwithstanding the requirements of subparagraph
28 15. to the contrary, establish a local matching requirement of
29 $0.00 for the Title XXI program in each county of the state
30 for the 2001-2002 fiscal year. This subparagraph shall take
31
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1 effect upon becoming a law and shall operate retroactively to
2 July 1, 2001. This subparagraph expires July 1, 2002.
3 Section 21. Section 624.915, Florida Statutes, is
4 created to read:
5 624.915 Local match requirement.--
6 (1) By May 1 of each year, the Florida Healthy Kids
7 Corporation established in s. 624.91 shall determine the local
8 match requirement for each county and provide written
9 notification to each county of the amount to be remitted to
10 the corporation for the following fiscal year.
11 (a) The corporation shall first annually establish a
12 nonmatch enrollment allocation per county which does not
13 require any local matching funds. For the purpose of
14 determining the nonmatch enrollment allocation, each county
15 shall be assigned to one of three tiers based on the county's
16 population of children, using the most recently released
17 federal census data. Enrollment slots shall be allocated to
18 each tier; however, no county shall receive fewer than 500
19 slots. Enrollment slots shall not be reserved for any
20 particular county, and unused slots may be redistributed by
21 the corporation to accommodate increased enrollment in other
22 counties.
23 (b) The corporation shall then determine the county's
24 local match percentage rate. For the purpose of determining
25 the local match percentage rate, each county shall be assigned
26 to one of three tiers based on the county's economic census in
27 the year of the most recently released federal census data.
28 The local match percentage rate for the lowest tier shall be
29 greater than zero but not more than 5 percent, and it shall be
30 no greater than 15 percent for the highest tier.
31
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1 (c) The corporation shall then calculate the local
2 match requirement for each county as the total annual
3 consideration paid by the corporation for the county's total
4 enrollee insurance premiums for the prior fiscal year, less
5 the value of the premiums for the county's nonmatch enrollment
6 for the same year, multiplied by the county's local match
7 percentage rate. The resulting local match requirement for
8 each county shall not be less than zero nor more than the
9 county paid in fiscal year 2000-2001.
10 (2) A county that disputes its tier assignment may
11 file a written grievance with the corporation for review by
12 the corporation's board of directors. The board's decision
13 shall be final and not subject to further review.
14 (3) The corporation's board of directors shall
15 determine the timing and method for payment of the required
16 local match to the corporation. For purposes of meeting the
17 local match requirement, at least 90 percent of the county's
18 local match requirement must be eligible to match federal
19 Title XXI funds. Local matching funds must be in the form of
20 cash. In-kind contributions will not be accepted for purposes
21 of compliance with a county's local match requirement.
22 Section 22. Subsection (28) of section 393.063,
23 Florida Statutes, is amended to read:
24 393.063 Definitions.--For the purposes of this
25 chapter:
26 (28) "Intermediate care facility for the
27 developmentally disabled" or "ICF/DD" means a
28 state-owned-and-operated residential facility licensed and
29 certified in accordance with state law, and certified by the
30 Federal Government pursuant to the Social Security Act, as a
31 provider of Medicaid services to persons who are
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1 developmentally disabled mentally retarded or who have related
2 conditions. The capacity of such a facility shall not be more
3 than 120 clients.
4 Section 23. Section 400.965, Florida Statutes, is
5 amended to read:
6 400.965 Action by agency against licensee; grounds.--
7 (1) Any of the following conditions constitute grounds
8 for action by the agency against a licensee:
9 (a) A misrepresentation of a material fact in the
10 application;
11 (b) The commission of an intentional or negligent act
12 materially affecting the health or safety of residents of the
13 facility;
14 (c) A violation of any provision of this part or rules
15 adopted under this part; or
16 (d) The commission of any act constituting a ground
17 upon which application for a license may be denied.
18 (2) If the agency has a reasonable belief that any of
19 such conditions exists, it shall:
20 (a) In the case of an applicant for original
21 licensure, deny the application.
22 (b) In the case of an applicant for relicensure or a
23 current licensee, take administrative action as provided in s.
24 400.968 or s. 400.969 or injunctive action as authorized by s.
25 400.963.
26 (c) In the case of a facility operating without a
27 license, take injunctive action as authorized in s. 400.963.
28 Section 24. Subsection (4) of section 400.968, Florida
29 Statutes, is renumbered as section 400.969, Florida Statutes,
30 and amended to read:
31 400.969 Violation of part; penalties.--
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1 (1)(4)(a) Except as provided in s. 400.967(3), a
2 violation of any provision of this part section or rules
3 adopted by the agency under this part section is punishable by
4 payment of an administrative or civil penalty not to exceed
5 $5,000.
6 (2)(b) A violation of this part section or of rules
7 adopted under this part section is a misdemeanor of the first
8 degree, punishable as provided in s. 775.082 or s. 775.083.
9 Each day of a continuing violation is a separate offense.
10 Section 25. By January 1, 2003, the Agency for Health
11 Care Administration shall make recommendations to the
12 Legislature as to limits in the amount of home office
13 management and administrative fees which should be allowable
14 for reimbursement for Medicaid providers whose rates are set
15 on a cost-reimbursement basis.
16 Section 26. Except as otherwise provided herein, this
17 act shall take effect upon becoming a law.
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