SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
CHAMBER ACTION
Senate House
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11 Senator Silver moved the following amendment:
12
13 Senate Amendment (with title amendment)
14 Delete everything after the enacting clause
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16 and insert:
17 Section 1. Section 16.59, Florida Statutes, is amended
18 to read:
19 16.59 Medicaid fraud control.--There is created in the
20 Department of Legal Affairs the Medicaid Fraud Control Unit,
21 which may investigate all violations of s. 409.920 and any
22 criminal violations discovered during the course of those
23 investigations. The Medicaid Fraud Control Unit may refer any
24 criminal violation so uncovered to the appropriate prosecuting
25 authority. Offices of the Medicaid Fraud Control Unit and the
26 offices of the Agency for Health Care Administration Medicaid
27 program integrity program shall, to the extent possible, be
28 collocated. The agency and the Department of Legal Affairs
29 shall conduct joint training and other joint activities
30 designed to increase communication and coordination in
31 recovering overpayments.
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 Section 2. Subsections (3), (5), and (7) of section
2 112.3187, Florida Statutes, are amended to read:
3 112.3187 Adverse action against employee for
4 disclosing information of specified nature prohibited;
5 employee remedy and relief.--
6 (3) DEFINITIONS.--As used in this act, unless
7 otherwise specified, the following words or terms shall have
8 the meanings indicated:
9 (a) "Agency" means any state, regional, county, local,
10 or municipal government entity, whether executive, judicial,
11 or legislative; any official, officer, department, division,
12 bureau, commission, authority, or political subdivision
13 therein; or any public school, community college, or state
14 university.
15 (b) "Employee" means a person who performs services
16 for, and under the control and direction of, or contracts
17 with, an agency or independent contractor for wages or other
18 remuneration.
19 (c) "Adverse personnel action" means the discharge,
20 suspension, transfer, or demotion of any employee or the
21 withholding of bonuses, the reduction in salary or benefits,
22 or any other adverse action taken against an employee within
23 the terms and conditions of employment by an agency or
24 independent contractor.
25 (d) "Independent contractor" means a person, other
26 than an agency, engaged in any business and who enters into a
27 contract or provider agreement with an agency.
28 (e) "Gross mismanagement" means a continuous pattern
29 of managerial abuses, wrongful or arbitrary and capricious
30 actions, or fraudulent or criminal conduct which may have a
31 substantial adverse economic impact.
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (5) NATURE OF INFORMATION DISCLOSED.--The information
2 disclosed under this section must include:
3 (a) Any violation or suspected violation of any
4 federal, state, or local law, rule, or regulation committed by
5 an employee or agent of an agency or independent contractor
6 which creates and presents a substantial and specific danger
7 to the public's health, safety, or welfare.
8 (b) Any act or suspected act of gross mismanagement,
9 malfeasance, misfeasance, gross waste of public funds,
10 suspected or actual Medicaid fraud or abuse, or gross neglect
11 of duty committed by an employee or agent of an agency or
12 independent contractor.
13 (7) EMPLOYEES AND PERSONS PROTECTED.--This section
14 protects employees and persons who disclose information on
15 their own initiative in a written and signed complaint; who
16 are requested to participate in an investigation, hearing, or
17 other inquiry conducted by any agency or federal government
18 entity; who refuse to participate in any adverse action
19 prohibited by this section; or who initiate a complaint
20 through the whistle-blower's hotline or the hotline of the
21 Medicaid Fraud Control Unit of the Department of Legal
22 Affairs; or employees who file any written complaint to their
23 supervisory officials or employees who submit a complaint to
24 the Chief Inspector General in the Executive Office of the
25 Governor, to the employee designated as agency inspector
26 general under s. 112.3189(1), or to the Florida Commission on
27 Human Relations. The provisions of this section may not be
28 used by a person while he or she is under the care, custody,
29 or control of the state correctional system or, after release
30 from the care, custody, or control of the state correctional
31 system, with respect to circumstances that occurred during any
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 period of incarceration. No remedy or other protection under
2 ss. 112.3187-112.31895 applies to any person who has committed
3 or intentionally participated in committing the violation or
4 suspected violation for which protection under ss.
5 112.3187-112.31895 is being sought.
6 Section 3. Paragraph (d) of subsection (5) of section
7 400.179, Florida Statutes, is amended to read:
8 400.179 Sale or transfer of ownership of a nursing
9 facility; liability for Medicaid underpayments and
10 overpayments.--
11 (5) Because any transfer of a nursing facility may
12 expose the fact that Medicaid may have underpaid or overpaid
13 the transferor, and because in most instances, any such
14 underpayment or overpayment can only be determined following a
15 formal field audit, the liabilities for any such underpayments
16 or overpayments shall be as follows:
17 (d) Where the transfer involves a facility that has
18 been leased by the transferor:
19 1. The transferee shall, as a condition to being
20 issued a license by the agency, acquire, maintain, and provide
21 proof to the agency of a bond with a term of 30 months,
22 renewable annually, in an amount not less than the total of 3
23 months Medicaid payments to the facility computed on the basis
24 of the preceding 12-month average Medicaid payments to the
25 facility.
26 2. The leasehold operator may meet the bond
27 requirement through other arrangements acceptable to the
28 department.
29 3. All existing nursing facility licensees, operating
30 the facility as a leasehold, shall acquire, maintain, and
31 provide proof to the agency of the 30-month bond required in
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 subparagraph 1., above, on and after July 1, 1993, for each
2 license renewal.
3 4. It shall be the responsibility of all nursing
4 facility operators, operating the facility as a leasehold, to
5 renew the 30-month bond and to provide proof of such renewal
6 to the agency annually at the time of application for license
7 renewal.
8 5. Any failure of the nursing facility operator to
9 acquire, maintain, renew annually, or provide proof to the
10 agency shall be grounds for the agency to deny, cancel,
11 revoke, or suspend the facility license to operate such
12 facility and to take any further action, including, but not
13 limited to, enjoining the facility, asserting a moratorium, or
14 applying for a receiver, deemed necessary to ensure compliance
15 with this section and to safeguard and protect the health,
16 safety, and welfare of the facility's residents.
17 6. Notwithstanding other provisions of this section, a
18 lease agreement required as a condition of bond financing or
19 refinancing under s. 154.213 by a health facilities authority
20 or under s. 159.30 by a county or municipality is not
21 considered as a leasehold and therefore, is not subject to the
22 bond requirement of this paragraph.
23 Section 4. Section 408.831, Florida Statutes, is
24 created to read:
25 408.831 Denial, suspension, revocation of a license,
26 registration, certificate or application.--
27 (1) In addition to any other remedies provided by law,
28 the agency may deny each application or suspend or revoke each
29 license, registration, or certificate of entities regulated or
30 licensed by it:
31 (a) If the applicant, licensee, registrant, or
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 certificateholder, or, in the case of a corporation,
2 partnership, or other business entity, if any officer,
3 director, agent, or managing employee of that business entity
4 or any affiliated person, partner, or shareholder having an
5 ownership interest equal to 5 percent or greater in that
6 business entity, has failed to pay all outstanding fines,
7 liens, or overpayments assessed by final order of the agency
8 or final order of the Centers for Medicare and Medicaid
9 Services, not subject to further appeal, unless a repayment
10 plan is approved by the agency; or
11 (b) For failure to comply with any repayment plan.
12 (2) This section provides standards of enforcement
13 applicable to all entities licensed or regulated by the Agency
14 for Health Care Administration. This section controls over any
15 conflicting provisions of chapters 39, 381, 383, 390, 391,
16 393, 394, 395, 400, 408, 468, 483, and 641 or rules adopted
17 pursuant to those chapters.
18 Section 5. Section 409.8177, Florida Statutes, is
19 amended to read:
20 409.8177 Program evaluation.--
21 (1) The agency, in consultation with the Department of
22 Health, the Department of Children and Family Services, and
23 the Florida Healthy Kids Corporation, shall contract for an
24 evaluation of the Florida Kidcare program and shall by January
25 1 of each year submit to the Governor, the President of the
26 Senate, and the Speaker of the House of Representatives a
27 report of the Florida Kidcare program. In addition to the
28 items specified under s. 2108 of Title XXI of the Social
29 Security Act, the report shall include an assessment of
30 crowd-out and access to health care, as well as the following:
31 (a)(1) An assessment of the operation of the program,
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 including the progress made in reducing the number of
2 uncovered low-income children.
3 (b)(2) An assessment of the effectiveness in
4 increasing the number of children with creditable health
5 coverage, including an assessment of the impact of outreach.
6 (c)(3) The characteristics of the children and
7 families assisted under the program, including ages of the
8 children, family income, and access to or coverage by other
9 health insurance prior to the program and after disenrollment
10 from the program.
11 (d)(4) The quality of health coverage provided,
12 including the types of benefits provided.
13 (e)(5) The amount and level, including payment of part
14 or all of any premium, of assistance provided.
15 (f)(6) The average length of coverage of a child under
16 the program.
17 (g)(7) The program's choice of health benefits
18 coverage and other methods used for providing child health
19 assistance.
20 (h)(8) The sources of nonfederal funding used in the
21 program.
22 (i)(9) An assessment of the effectiveness of Medikids,
23 Children's Medical Services network, and other public and
24 private programs in the state in increasing the availability
25 of affordable quality health insurance and health care for
26 children.
27 (j)(10) A review and assessment of state activities to
28 coordinate the program with other public and private programs.
29 (k)(11) An analysis of changes and trends in the state
30 that affect the provision of health insurance and health care
31 to children.
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (l)(12) A description of any plans the state has for
2 improving the availability of health insurance and health care
3 for children.
4 (m)(13) Recommendations for improving the program.
5 (n)(14) Other studies as necessary.
6 (2) The agency shall also submit each month to the
7 Governor, the President of the Senate, and the Speaker of the
8 House of Representatives a report of enrollment for each
9 program component of the Florida Kidcare program.
10 Section 6. Section 409.902, Florida Statutes, is
11 amended to read:
12 409.902 Designated single state agency; payment
13 requirements; program title; release of medical records.--The
14 Agency for Health Care Administration is designated as the
15 single state agency authorized to make payments for medical
16 assistance and related services under Title XIX of the Social
17 Security Act. These payments shall be made, subject to any
18 limitations or directions provided for in the General
19 Appropriations Act, only for services included in the program,
20 shall be made only on behalf of eligible individuals, and
21 shall be made only to qualified providers in accordance with
22 federal requirements for Title XIX of the Social Security Act
23 and the provisions of state law. This program of medical
24 assistance is designated the "Medicaid program." The
25 Department of Children and Family Services is responsible for
26 Medicaid eligibility determinations, including, but not
27 limited to, policy, rules, and the agreement with the Social
28 Security Administration for Medicaid eligibility
29 determinations for Supplemental Security Income recipients, as
30 well as the actual determination of eligibility. As a
31 condition of Medicaid eligibility, the Agency for Health Care
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 Administration and the Department of Children and Family
2 Services shall ensure that each recipient of Medicaid consents
3 to the release of her or his medical records to the Agency for
4 Health Care Administration and the Medicaid Fraud Control Unit
5 of the Department of Legal Affairs.
6 Section 7. Effective July 1, 2002, subsection (2) of
7 section 409.904, Florida Statutes, as amended by section 2 of
8 chapter 2001-377, Laws of Florida, is amended to read:
9 409.904 Optional payments for eligible persons.--The
10 agency may make payments for medical assistance and related
11 services on behalf of the following persons who are determined
12 to be eligible subject to the income, assets, and categorical
13 eligibility tests set forth in federal and state law. Payment
14 on behalf of these Medicaid eligible persons is subject to the
15 availability of moneys and any limitations established by the
16 General Appropriations Act or chapter 216.
17 (2)(a) A caretaker relative/parent, a pregnant woman,
18 a child under age 19 who would otherwise qualify for Florida
19 Kidcare Medicaid, a child up to age 21 who would otherwise
20 qualify under s. 409.903(1), a person age 65 or over, or a
21 blind or disabled person who would otherwise be eligible for
22 Florida Medicaid, except that the income or assets of such
23 family or person exceed established limitations. A pregnant
24 woman who would otherwise qualify for Medicaid under s.
25 409.903(5) except for her level of income and whose assets
26 fall within the limits established by the Department of
27 Children and Family Services for the medically needy. A
28 pregnant woman who applies for medically needy eligibility may
29 not be made presumptively eligible.
30 (b) A child under age 21 who would otherwise qualify
31 for Medicaid or the Florida Kidcare program except for the
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 family's level of income and whose assets fall within the
2 limits established by the Department of Children and Family
3 Services for the medically needy.
4
5 For a family or person in one of these coverage groups this
6 group, medical expenses are deductible from income in
7 accordance with federal requirements in order to make a
8 determination of eligibility. Expenses used to meet spend-down
9 liability are not reimbursable by Medicaid. Effective January
10 1, 2003, when determining the eligibility of a pregnant woman,
11 a child, or an aged, blind, or disabled individual, $270 will
12 be deducted from the countable income of the filing unit. When
13 determining the eligibility of the parent or caretaker
14 relative as defined by Title XIX of the Social Security Act,
15 the additional income disregard of $270 does not apply. A
16 family or person eligible under the coverage in this group,
17 which group is known as the "medically needy," is eligible to
18 receive the same services as other Medicaid recipients, with
19 the exception of services in skilled nursing facilities and
20 intermediate care facilities for the developmentally disabled.
21 Section 8. Paragraph (c) of subsection (5) of section
22 409.905, Florida Statutes, is amended to read:
23 409.905 Mandatory Medicaid services.--The agency may
24 make payments for the following services, which are required
25 of the state by Title XIX of the Social Security Act,
26 furnished by Medicaid providers to recipients who are
27 determined to be eligible on the dates on which the services
28 were provided. Any service under this section shall be
29 provided only when medically necessary and in accordance with
30 state and federal law. Mandatory services rendered by
31 providers in mobile units to Medicaid recipients may be
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 restricted by the agency. Nothing in this section shall be
2 construed to prevent or limit the agency from adjusting fees,
3 reimbursement rates, lengths of stay, number of visits, number
4 of services, or any other adjustments necessary to comply with
5 the availability of moneys and any limitations or directions
6 provided for in the General Appropriations Act or chapter 216.
7 (5) HOSPITAL INPATIENT SERVICES.--The agency shall pay
8 for all covered services provided for the medical care and
9 treatment of a recipient who is admitted as an inpatient by a
10 licensed physician or dentist to a hospital licensed under
11 part I of chapter 395. However, the agency shall limit the
12 payment for inpatient hospital services for a Medicaid
13 recipient 21 years of age or older to 45 days or the number of
14 days necessary to comply with the General Appropriations Act.
15 (c) Agency for Health Care Administration shall adjust
16 a hospital's current inpatient per diem rate to reflect the
17 cost of serving the Medicaid population at that institution
18 if:
19 1. The hospital experiences an increase in Medicaid
20 caseload by more than 25 percent in any year, primarily
21 resulting from the closure of a hospital in the same service
22 area occurring after July 1, 1995; or
23 2. The hospital's Medicaid per diem rate is at least
24 25 percent below the Medicaid per patient cost for that year;
25 or.
26 3. The hospital is located in a county that has five
27 or fewer hospitals, began offering obstetrical services on or
28 after September 1999, and has submitted a request in writing
29 to the agency for a rate adjustment after July 1, 2000, but
30 before September 30, 2000, in which case such hospital's
31 Medicaid inpatient per diem rate shall be adjusted to cost,
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 effective July 1, 2002.
2
3 No later than October 1 of each year November 1, 2001, the
4 agency must provide estimated costs for any adjustment in a
5 hospital inpatient per diem pursuant to this paragraph to the
6 Executive Office of the Governor, the House of Representatives
7 General Appropriations Committee, and the Senate
8 Appropriations Committee. Before the agency implements a
9 change in a hospital's inpatient per diem rate pursuant to
10 this paragraph, the Legislature must have specifically
11 appropriated sufficient funds in the General Appropriations
12 Act to support the increase in cost as estimated by the
13 agency.
14 Section 9. Effective July 1, 2002, subsections (1),
15 (12), and (23) of section 409.906, Florida Statutes, as
16 amended by section 3 of chapter 2001-377, Laws of Florida, are
17 amended to read:
18 409.906 Optional Medicaid services.--Subject to
19 specific appropriations, the agency may make payments for
20 services which are optional to the state under Title XIX of
21 the Social Security Act and are furnished by Medicaid
22 providers to recipients who are determined to be eligible on
23 the dates on which the services were provided. Any optional
24 service that is provided shall be provided only when medically
25 necessary and in accordance with state and federal law.
26 Optional services rendered by providers in mobile units to
27 Medicaid recipients may be restricted or prohibited by the
28 agency. Nothing in this section shall be construed to prevent
29 or limit the agency from adjusting fees, reimbursement rates,
30 lengths of stay, number of visits, or number of services, or
31 making any other adjustments necessary to comply with the
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 availability of moneys and any limitations or directions
2 provided for in the General Appropriations Act or chapter 216.
3 If necessary to safeguard the state's systems of providing
4 services to elderly and disabled persons and subject to the
5 notice and review provisions of s. 216.177, the Governor may
6 direct the Agency for Health Care Administration to amend the
7 Medicaid state plan to delete the optional Medicaid service
8 known as "Intermediate Care Facilities for the Developmentally
9 Disabled." Optional services may include:
10 (1) ADULT DENTURE SERVICES.--The agency may pay for
11 dentures, the procedures required to seat dentures, and the
12 repair and reline of dentures, provided by or under the
13 direction of a licensed dentist, for a recipient who is age 21
14 or older. However, Medicaid will not provide reimbursement for
15 dental services provided in a mobile dental unit, except for a
16 mobile dental unit:
17 (a) Owned by, operated by, or having a contractual
18 agreement with the Department of Health and complying with
19 Medicaid's county health department clinic services program
20 specifications as a county health department clinic services
21 provider.
22 (b) Owned by, operated by, or having a contractual
23 arrangement with a federally qualified health center and
24 complying with Medicaid's federally qualified health center
25 specifications as a federally qualified health center
26 provider.
27 (c) Rendering dental services to Medicaid recipients,
28 21 years of age and older, at nursing facilities.
29 (d) Owned by, operated by, or having a contractual
30 agreement with a state-approved dental educational
31 institution.
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (e) This subsection is repealed July 1, 2002.
2 (12) CHILDREN'S HEARING SERVICES.--The agency may pay
3 for hearing and related services, including hearing
4 evaluations, hearing aid devices, dispensing of the hearing
5 aid, and related repairs, if provided to a recipient under age
6 21 by a licensed hearing aid specialist, otolaryngologist,
7 otologist, audiologist, or physician.
8 (23) CHILDREN'S VISUAL SERVICES.--The agency may pay
9 for visual examinations, eyeglasses, and eyeglass repairs for
10 a recipient under age 21, if they are prescribed by a licensed
11 physician specializing in diseases of the eye or by a licensed
12 optometrist.
13 Section 10. Subsection (2) of section 409.9065,
14 Florida Statutes, as amended by section 5 of chapter 2001-377,
15 Laws of Florida, is amended to read:
16 409.9065 Pharmaceutical expense assistance.--
17 (2) ELIGIBILITY.--Eligibility for the program is
18 limited to those individuals who qualify for limited
19 assistance under the Florida Medicaid program as a result of
20 being dually eligible for both Medicare and Medicaid, but
21 whose limited assistance or Medicare coverage does not include
22 any pharmacy benefit. To the extent funds are appropriated,
23 specifically eligible individuals are individuals low-income
24 senior citizens who:
25 (a) Are Florida residents age 65 and over;
26 (b) Have an income:
27 1. Between 88 90 and 120 percent of the federal
28 poverty level;
29 2. Between 88 and 150 percent of the federal poverty
30 level if the Federal Government increases the federal Medicaid
31 match for persons between 100 and 150 percent of the federal
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Amendment No. ___ Barcode 934922
1 poverty level; or
2 3. Between 88 percent of the federal poverty level and
3 a level that can be supported with funds provided in the
4 General Appropriations Act for the program offered under this
5 section along with federal matching funds approved by the
6 Federal Government under a s. 1115 waiver. The agency is
7 authorized to submit and implement a federal waiver pursuant
8 to this subparagraph. The agency shall design a pharmacy
9 benefit that includes annual per-member benefit limits and
10 cost-sharing provisions and limits enrollment to available
11 appropriations and matching federal funds. Prior to
12 implementing this program, the agency must submit a budget
13 amendment pursuant to chapter 216;
14 (c) Are eligible for both Medicare and Medicaid;
15 (d) Are not enrolled in a Medicare health maintenance
16 organization that provides a pharmacy benefit; and
17 (e) Request to be enrolled in the program.
18 Section 11. Subsections (7) and (9) of section
19 409.907, Florida Statutes, as amended by section 6 of chapter
20 2001-377, Laws of Florida, are amended to read:
21 409.907 Medicaid provider agreements.--The agency may
22 make payments for medical assistance and related services
23 rendered to Medicaid recipients only to an individual or
24 entity who has a provider agreement in effect with the agency,
25 who is performing services or supplying goods in accordance
26 with federal, state, and local law, and who agrees that no
27 person shall, on the grounds of handicap, race, color, or
28 national origin, or for any other reason, be subjected to
29 discrimination under any program or activity for which the
30 provider receives payment from the agency.
31 (7) The agency may require, as a condition of
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Amendment No. ___ Barcode 934922
1 participating in the Medicaid program and before entering into
2 the provider agreement, that the provider submit information,
3 in an initial and any required renewal applications,
4 concerning the professional, business, and personal background
5 of the provider and permit an onsite inspection of the
6 provider's service location by agency staff or other personnel
7 designated by the agency to perform this function. The agency
8 shall perform a random onsite inspection, within 60 days after
9 receipt of a fully complete new provider's application, of the
10 provider's service location prior to making its first payment
11 to the provider for Medicaid services to determine the
12 applicant's ability to provide the services that the applicant
13 is proposing to provide for Medicaid reimbursement. The agency
14 is not required to perform an onsite inspection of a provider
15 or program that is licensed by the agency, that provides
16 services under waiver programs for home and community-based
17 services, or that is licensed as a medical foster home by the
18 Department of Children and Family Services. As a continuing
19 condition of participation in the Medicaid program, a provider
20 shall immediately notify the agency of any current or pending
21 bankruptcy filing. Before entering into the provider
22 agreement, or as a condition of continuing participation in
23 the Medicaid program, the agency may also require that
24 Medicaid providers reimbursed on a fee-for-services basis or
25 fee schedule basis which is not cost-based, post a surety bond
26 not to exceed $50,000 or the total amount billed by the
27 provider to the program during the current or most recent
28 calendar year, whichever is greater. For new providers, the
29 amount of the surety bond shall be determined by the agency
30 based on the provider's estimate of its first year's billing.
31 If the provider's billing during the first year exceeds the
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Amendment No. ___ Barcode 934922
1 bond amount, the agency may require the provider to acquire an
2 additional bond equal to the actual billing level of the
3 provider. A provider's bond shall not exceed $50,000 if a
4 physician or group of physicians licensed under chapter 458,
5 chapter 459, or chapter 460 has a 50 percent or greater
6 ownership interest in the provider or if the provider is an
7 assisted living facility licensed under part III of chapter
8 400. The bonds permitted by this section are in addition to
9 the bonds referenced in s. 400.179(4)(d). If the provider is a
10 corporation, partnership, association, or other entity, the
11 agency may require the provider to submit information
12 concerning the background of that entity and of any principal
13 of the entity, including any partner or shareholder having an
14 ownership interest in the entity equal to 5 percent or
15 greater, and any treating provider who participates in or
16 intends to participate in Medicaid through the entity. The
17 information must include:
18 (a) Proof of holding a valid license or operating
19 certificate, as applicable, if required by the state or local
20 jurisdiction in which the provider is located or if required
21 by the Federal Government.
22 (b) Information concerning any prior violation, fine,
23 suspension, termination, or other administrative action taken
24 under the Medicaid laws, rules, or regulations of this state
25 or of any other state or the Federal Government; any prior
26 violation of the laws, rules, or regulations relating to the
27 Medicare program; any prior violation of the rules or
28 regulations of any other public or private insurer; and any
29 prior violation of the laws, rules, or regulations of any
30 regulatory body of this or any other state.
31 (c) Full and accurate disclosure of any financial or
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1 ownership interest that the provider, or any principal,
2 partner, or major shareholder thereof, may hold in any other
3 Medicaid provider or health care related entity or any other
4 entity that is licensed by the state to provide health or
5 residential care and treatment to persons.
6 (d) If a group provider, identification of all members
7 of the group and attestation that all members of the group are
8 enrolled in or have applied to enroll in the Medicaid program.
9 (9) Upon receipt of a completed, signed, and dated
10 application, and completion of any necessary background
11 investigation and criminal history record check, the agency
12 must either:
13 (a) Enroll the applicant as a Medicaid provider no
14 earlier than the effective date of the approval of the
15 provider application. With respect to providers who were
16 recently granted a change of ownership and those who primarily
17 provide emergency medical services transportation or emergency
18 services and care pursuant to s. 401.45 or s. 395.1041, and
19 out-of-state providers, upon approval of the provider
20 application, the effective date of approval is considered to
21 be the date the agency receives the provider application; or
22 (b) Deny the application if the agency finds that it
23 is in the best interest of the Medicaid program to do so. The
24 agency may consider the factors listed in subsection (10), as
25 well as any other factor that could affect the effective and
26 efficient administration of the program, including, but not
27 limited to, the applicant's demonstrated ability to provide
28 services, conduct business, and operate a financially viable
29 concern; the current availability of medical care, services,
30 or supplies to recipients, taking into account geographic
31 location and reasonable travel time; the number of providers
18
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 of the same type already enrolled in the same geographic area;
2 and the credentials, experience, success, and patient outcomes
3 of the provider for the services that it is making application
4 to provide in the Medicaid program. The agency shall deny the
5 application if the agency finds that a provider; any officer,
6 director, agent, managing employee, or affiliated person; or
7 any partner or shareholder having an ownership interest equal
8 to 5 percent or greater in the provider if the provider is a
9 corporation, partnership, or other business entity, has failed
10 to pay all outstanding fines or overpayments assessed by final
11 order of the agency or final order of the Centers for Medicare
12 and Medicaid Services, not subject to further appeal, unless
13 the provider agrees to a repayment plan that includes
14 withholding Medicaid reimbursement until the amount due is
15 paid in full.
16 Section 12. Section 409.908, Florida Statutes, as
17 amended by section 7 of chapter 2001-377, Laws of Florida, is
18 amended to read:
19 409.908 Reimbursement of Medicaid providers.--Subject
20 to specific appropriations, the agency shall reimburse
21 Medicaid providers, in accordance with state and federal law,
22 according to methodologies set forth in the rules of the
23 agency and in policy manuals and handbooks incorporated by
24 reference therein. These methodologies may include fee
25 schedules, reimbursement methods based on cost reporting,
26 negotiated fees, competitive bidding pursuant to s. 287.057,
27 and other mechanisms the agency considers efficient and
28 effective for purchasing services or goods on behalf of
29 recipients. If a provider is reimbursed based on cost
30 reporting and submits a cost report late and that cost report
31 would have been used to set a lower reimbursement rate for a
19
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 rate semester, then the provider's rate for that semester
2 shall be retroactively calculated using the new cost report,
3 and full payment at the recalculated rate shall be effected
4 retroactively. Medicare granted extensions for filing cost
5 reports, if applicable, shall also apply to Medicaid cost
6 reports. Payment for Medicaid compensable services made on
7 behalf of Medicaid eligible persons is subject to the
8 availability of moneys and any limitations or directions
9 provided for in the General Appropriations Act or chapter 216.
10 Further, nothing in this section shall be construed to prevent
11 or limit the agency from adjusting fees, reimbursement rates,
12 lengths of stay, number of visits, or number of services, or
13 making any other adjustments necessary to comply with the
14 availability of moneys and any limitations or directions
15 provided for in the General Appropriations Act, provided the
16 adjustment is consistent with legislative intent.
17 (1) Reimbursement to hospitals licensed under part I
18 of chapter 395 must be made prospectively or on the basis of
19 negotiation.
20 (a) Reimbursement for inpatient care is limited as
21 provided for in s. 409.905(5), except for:
22 1. The raising of rate reimbursement caps, excluding
23 rural hospitals.
24 2. Recognition of the costs of graduate medical
25 education.
26 3. Other methodologies recognized in the General
27 Appropriations Act.
28 4. Hospital inpatient rates shall be reduced by 6
29 percent effective July 1, 2001, and restored effective April
30 1, 2002.
31
20
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 During the years funds are transferred from the Department of
2 Health, any reimbursement supported by such funds shall be
3 subject to certification by the Department of Health that the
4 hospital has complied with s. 381.0403. The agency is
5 authorized to receive funds from state entities, including,
6 but not limited to, the Department of Health, local
7 governments, and other local political subdivisions, for the
8 purpose of making special exception payments, including
9 federal matching funds, through the Medicaid inpatient
10 reimbursement methodologies. Funds received from state
11 entities or local governments for this purpose shall be
12 separately accounted for and shall not be commingled with
13 other state or local funds in any manner. The agency may
14 certify all local governmental funds used as state match under
15 Title XIX of the Social Security Act, to the extent that the
16 identified local health care provider that is otherwise
17 entitled to and is contracted to receive such local funds is
18 the benefactor under the state's Medicaid program as
19 determined under the General Appropriations Act and pursuant
20 to an agreement between the Agency for Health Care
21 Administration and the local governmental entity. The local
22 governmental entity shall use a certification form prescribed
23 by the agency. At a minimum, the certification form shall
24 identify the amount being certified and describe the
25 relationship between the certifying local governmental entity
26 and the local health care provider. The agency shall prepare
27 an annual statement of impact which documents the specific
28 activities undertaken during the previous fiscal year pursuant
29 to this paragraph, to be submitted to the Legislature no later
30 than January 1, annually.
31 (b) Reimbursement for hospital outpatient care is
21
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 limited to $1,500 per state fiscal year per recipient, except
2 for:
3 1. Such care provided to a Medicaid recipient under
4 age 21, in which case the only limitation is medical
5 necessity.
6 2. Renal dialysis services.
7 3. Other exceptions made by the agency.
8
9 The agency is authorized to receive funds from state entities,
10 including, but not limited to, the Department of Health, the
11 Board of Regents, local governments, and other local political
12 subdivisions, for the purpose of making payments, including
13 federal matching funds, through the Medicaid outpatient
14 reimbursement methodologies. Funds received from state
15 entities and local governments for this purpose shall be
16 separately accounted for and shall not be commingled with
17 other state or local funds in any manner.
18 (c) Hospitals that provide services to a
19 disproportionate share of low-income Medicaid recipients, or
20 that participate in the regional perinatal intensive care
21 center program under chapter 383, or that participate in the
22 statutory teaching hospital disproportionate share program may
23 receive additional reimbursement. The total amount of payment
24 for disproportionate share hospitals shall be fixed by the
25 General Appropriations Act. The computation of these payments
26 must be made in compliance with all federal regulations and
27 the methodologies described in ss. 409.911, 409.9112, and
28 409.9113.
29 (d) The agency is authorized to limit inflationary
30 increases for outpatient hospital services as directed by the
31 General Appropriations Act.
22
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (2)(a)1. Reimbursement to nursing homes licensed under
2 part II of chapter 400 and state-owned-and-operated
3 intermediate care facilities for the developmentally disabled
4 licensed under chapter 393 must be made prospectively.
5 2. Unless otherwise limited or directed in the General
6 Appropriations Act, reimbursement to hospitals licensed under
7 part I of chapter 395 for the provision of swing-bed nursing
8 home services must be made on the basis of the average
9 statewide nursing home payment, and reimbursement to a
10 hospital licensed under part I of chapter 395 for the
11 provision of skilled nursing services must be made on the
12 basis of the average nursing home payment for those services
13 in the county in which the hospital is located. When a
14 hospital is located in a county that does not have any
15 community nursing homes, reimbursement must be determined by
16 averaging the nursing home payments, in counties that surround
17 the county in which the hospital is located. Reimbursement to
18 hospitals, including Medicaid payment of Medicare copayments,
19 for skilled nursing services shall be limited to 30 days,
20 unless a prior authorization has been obtained from the
21 agency. Medicaid reimbursement may be extended by the agency
22 beyond 30 days, and approval must be based upon verification
23 by the patient's physician that the patient requires
24 short-term rehabilitative and recuperative services only, in
25 which case an extension of no more than 15 days may be
26 approved. Reimbursement to a hospital licensed under part I of
27 chapter 395 for the temporary provision of skilled nursing
28 services to nursing home residents who have been displaced as
29 the result of a natural disaster or other emergency may not
30 exceed the average county nursing home payment for those
31 services in the county in which the hospital is located and is
23
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 limited to the period of time which the agency considers
2 necessary for continued placement of the nursing home
3 residents in the hospital.
4 (b) Subject to any limitations or directions provided
5 for in the General Appropriations Act, the agency shall
6 establish and implement a Florida Title XIX Long-Term Care
7 Reimbursement Plan (Medicaid) for nursing home care in order
8 to provide care and services in conformance with the
9 applicable state and federal laws, rules, regulations, and
10 quality and safety standards and to ensure that individuals
11 eligible for medical assistance have reasonable geographic
12 access to such care.
13 1. Changes of ownership or of licensed operator do not
14 qualify for increases in reimbursement rates associated with
15 the change of ownership or of licensed operator. The agency
16 shall amend the Title XIX Long Term Care Reimbursement Plan to
17 provide that the initial nursing home reimbursement rates, for
18 the operating, patient care, and MAR components, associated
19 with related and unrelated party changes of ownership or
20 licensed operator filed on or after September 1, 2001, are
21 equivalent to the previous owner's reimbursement rate.
22 2. The agency shall amend the long-term care
23 reimbursement plan and cost reporting system to create direct
24 care and indirect care subcomponents of the patient care
25 component of the per diem rate. These two subcomponents
26 together shall equal the patient care component of the per
27 diem rate. Separate cost-based ceilings shall be calculated
28 for each patient care subcomponent. The direct care
29 subcomponent of the per diem rate shall be limited by the
30 cost-based class ceiling, and the indirect care subcomponent
31 shall be limited by the lower of the cost-based class ceiling,
24
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 by the target rate class ceiling, or by the individual
2 provider target. The agency shall adjust the patient care
3 component effective January 1, 2002. The cost to adjust the
4 direct care subcomponent shall be net of the total funds
5 previously allocated for the case mix add-on. The agency shall
6 make the required changes to the nursing home cost reporting
7 forms to implement this requirement effective January 1, 2002.
8 3. The direct care subcomponent shall include salaries
9 and benefits of direct care staff providing nursing services
10 including registered nurses, licensed practical nurses, and
11 certified nursing assistants who deliver care directly to
12 residents in the nursing home facility. This excludes nursing
13 administration, MDS, and care plan coordinators, staff
14 development, and staffing coordinator.
15 4. All other patient care costs shall be included in
16 the indirect care cost subcomponent of the patient care per
17 diem rate. There shall be no costs directly or indirectly
18 allocated to the direct care subcomponent from a home office
19 or management company.
20 5. On July 1 of each year, the agency shall report to
21 the Legislature direct and indirect care costs, including
22 average direct and indirect care costs per resident per
23 facility and direct care and indirect care salaries and
24 benefits per category of staff member per facility.
25 6. Under the plan, interim rate adjustments shall not
26 be granted to reflect increases in the cost of general or
27 professional liability insurance for nursing homes unless the
28 following criteria are met: have at least a 65 percent
29 Medicaid utilization in the most recent cost report submitted
30 to the agency, and the increase in general or professional
31 liability costs to the facility for the most recent policy
25
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 period affects the total Medicaid per diem by at least 5
2 percent. This rate adjustment shall not result in the per diem
3 exceeding the class ceiling. This provision shall be
4 implemented to the extent existing appropriations are
5 available.
6
7 It is the intent of the Legislature that the reimbursement
8 plan achieve the goal of providing access to health care for
9 nursing home residents who require large amounts of care while
10 encouraging diversion services as an alternative to nursing
11 home care for residents who can be served within the
12 community. The agency shall base the establishment of any
13 maximum rate of payment, whether overall or component, on the
14 available moneys as provided for in the General Appropriations
15 Act. The agency may base the maximum rate of payment on the
16 results of scientifically valid analysis and conclusions
17 derived from objective statistical data pertinent to the
18 particular maximum rate of payment.
19 (3) Subject to any limitations or directions provided
20 for in the General Appropriations Act, the following Medicaid
21 services and goods may be reimbursed on a fee-for-service
22 basis. For each allowable service or goods furnished in
23 accordance with Medicaid rules, policy manuals, handbooks, and
24 state and federal law, the payment shall be the amount billed
25 by the provider, the provider's usual and customary charge, or
26 the maximum allowable fee established by the agency, whichever
27 amount is less, with the exception of those services or goods
28 for which the agency makes payment using a methodology based
29 on capitation rates, average costs, or negotiated fees.
30 (a) Advanced registered nurse practitioner services.
31 (b) Birth center services.
26
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (c) Chiropractic services.
2 (d) Community mental health services.
3 (e) Dental services, including oral and maxillofacial
4 surgery.
5 (f) Durable medical equipment.
6 (g) Hearing services.
7 (h) Occupational therapy for Medicaid recipients under
8 age 21.
9 (i) Optometric services.
10 (j) Orthodontic services.
11 (k) Personal care for Medicaid recipients under age
12 21.
13 (l) Physical therapy for Medicaid recipients under age
14 21.
15 (m) Physician assistant services.
16 (n) Podiatric services.
17 (o) Portable X-ray services.
18 (p) Private-duty nursing for Medicaid recipients under
19 age 21.
20 (q) Registered nurse first assistant services.
21 (r) Respiratory therapy for Medicaid recipients under
22 age 21.
23 (s) Speech therapy for Medicaid recipients under age
24 21.
25 (t) Visual services.
26 (4) Subject to any limitations or directions provided
27 for in the General Appropriations Act, alternative health
28 plans, health maintenance organizations, and prepaid health
29 plans shall be reimbursed a fixed, prepaid amount negotiated,
30 or competitively bid pursuant to s. 287.057, by the agency and
31 prospectively paid to the provider monthly for each Medicaid
27
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 recipient enrolled. The amount may not exceed the average
2 amount the agency determines it would have paid, based on
3 claims experience, for recipients in the same or similar
4 category of eligibility. The agency shall calculate
5 capitation rates on a regional basis and, beginning September
6 1, 1995, shall include age-band differentials in such
7 calculations. Effective July 1, 2001, the cost of exempting
8 statutory teaching hospitals, specialty hospitals, and
9 community hospital education program hospitals from
10 reimbursement ceilings and the cost of special Medicaid
11 payments shall not be included in premiums paid to health
12 maintenance organizations or prepaid health care plans. Each
13 rate semester, the agency shall calculate and publish a
14 Medicaid hospital rate schedule that does not reflect either
15 special Medicaid payments or the elimination of rate
16 reimbursement ceilings, to be used by hospitals and Medicaid
17 health maintenance organizations, in order to determine the
18 Medicaid rate referred to in ss. 409.912(16), 409.9128(5), and
19 641.513(6).
20 (5) An ambulatory surgical center shall be reimbursed
21 the lesser of the amount billed by the provider or the
22 Medicare-established allowable amount for the facility.
23 (6) A provider of early and periodic screening,
24 diagnosis, and treatment services to Medicaid recipients who
25 are children under age 21 shall be reimbursed using an
26 all-inclusive rate stipulated in a fee schedule established by
27 the agency. A provider of the visual, dental, and hearing
28 components of such services shall be reimbursed the lesser of
29 the amount billed by the provider or the Medicaid maximum
30 allowable fee established by the agency.
31 (7) A provider of family planning services shall be
28
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 reimbursed the lesser of the amount billed by the provider or
2 an all-inclusive amount per type of visit for physicians and
3 advanced registered nurse practitioners, as established by the
4 agency in a fee schedule.
5 (8) A provider of home-based or community-based
6 services rendered pursuant to a federally approved waiver
7 shall be reimbursed based on an established or negotiated rate
8 for each service. These rates shall be established according
9 to an analysis of the expenditure history and prospective
10 budget developed by each contract provider participating in
11 the waiver program, or under any other methodology adopted by
12 the agency and approved by the Federal Government in
13 accordance with the waiver. Effective July 1, 1996, privately
14 owned and operated community-based residential facilities
15 which meet agency requirements and which formerly received
16 Medicaid reimbursement for the optional intermediate care
17 facility for the mentally retarded service may participate in
18 the developmental services waiver as part of a
19 home-and-community-based continuum of care for Medicaid
20 recipients who receive waiver services.
21 (9) A provider of home health care services or of
22 medical supplies and appliances shall be reimbursed on the
23 basis of competitive bidding or for the lesser of the amount
24 billed by the provider or the agency's established maximum
25 allowable amount, except that, in the case of the rental of
26 durable medical equipment, the total rental payments may not
27 exceed the purchase price of the equipment over its expected
28 useful life or the agency's established maximum allowable
29 amount, whichever amount is less.
30 (10) A hospice shall be reimbursed through a
31 prospective system for each Medicaid hospice patient at
29
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 Medicaid rates using the methodology established for hospice
2 reimbursement pursuant to Title XVIII of the federal Social
3 Security Act.
4 (11) A provider of independent laboratory services
5 shall be reimbursed on the basis of competitive bidding or for
6 the least of the amount billed by the provider, the provider's
7 usual and customary charge, or the Medicaid maximum allowable
8 fee established by the agency.
9 (12)(a) A physician shall be reimbursed the lesser of
10 the amount billed by the provider or the Medicaid maximum
11 allowable fee established by the agency.
12 (b) The agency shall adopt a fee schedule, subject to
13 any limitations or directions provided for in the General
14 Appropriations Act, based on a resource-based relative value
15 scale for pricing Medicaid physician services. Under this fee
16 schedule, physicians shall be paid a dollar amount for each
17 service based on the average resources required to provide the
18 service, including, but not limited to, estimates of average
19 physician time and effort, practice expense, and the costs of
20 professional liability insurance. The fee schedule shall
21 provide increased reimbursement for preventive and primary
22 care services and lowered reimbursement for specialty services
23 by using at least two conversion factors, one for cognitive
24 services and another for procedural services. The fee
25 schedule shall not increase total Medicaid physician
26 expenditures unless moneys are available, and shall be phased
27 in over a 2-year period beginning on July 1, 1994. The Agency
28 for Health Care Administration shall seek the advice of a
29 16-member advisory panel in formulating and adopting the fee
30 schedule. The panel shall consist of Medicaid physicians
31 licensed under chapters 458 and 459 and shall be composed of
30
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 50 percent primary care physicians and 50 percent specialty
2 care physicians.
3 (c) Notwithstanding paragraph (b), reimbursement fees
4 to physicians for providing total obstetrical services to
5 Medicaid recipients, which include prenatal, delivery, and
6 postpartum care, shall be at least $1,500 per delivery for a
7 pregnant woman with low medical risk and at least $2,000 per
8 delivery for a pregnant woman with high medical risk. However,
9 reimbursement to physicians working in Regional Perinatal
10 Intensive Care Centers designated pursuant to chapter 383, for
11 services to certain pregnant Medicaid recipients with a high
12 medical risk, may be made according to obstetrical care and
13 neonatal care groupings and rates established by the agency.
14 Nurse midwives licensed under part I of chapter 464 or
15 midwives licensed under chapter 467 shall be reimbursed at no
16 less than 80 percent of the low medical risk fee. The agency
17 shall by rule determine, for the purpose of this paragraph,
18 what constitutes a high or low medical risk pregnant woman and
19 shall not pay more based solely on the fact that a caesarean
20 section was performed, rather than a vaginal delivery. The
21 agency shall by rule determine a prorated payment for
22 obstetrical services in cases where only part of the total
23 prenatal, delivery, or postpartum care was performed. The
24 Department of Health shall adopt rules for appropriate
25 insurance coverage for midwives licensed under chapter 467.
26 Prior to the issuance and renewal of an active license, or
27 reactivation of an inactive license for midwives licensed
28 under chapter 467, such licensees shall submit proof of
29 coverage with each application.
30 (d) For fiscal years 2001-2002 and 2002-2003 the
31 2001-2002 fiscal year only and if necessary to meet the
31
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 requirements for grants and donations for the special Medicaid
2 payments authorized in the 2001-2002 and 2002-2003 General
3 Appropriations Acts Act, the agency may make special Medicaid
4 payments to qualified Medicaid providers designated by the
5 agency, notwithstanding any provision of this subsection to
6 the contrary, and may use intergovernmental transfers from
7 state entities or other governmental entities to serve as the
8 state share of such payments.
9 (13) Medicare premiums for persons eligible for both
10 Medicare and Medicaid coverage shall be paid at the rates
11 established by Title XVIII of the Social Security Act. For
12 Medicare services rendered to Medicaid-eligible persons,
13 Medicaid shall pay Medicare deductibles and coinsurance as
14 follows:
15 (a) Medicaid shall make no payment toward deductibles
16 and coinsurance for any service that is not covered by
17 Medicaid.
18 (b) Medicaid's financial obligation for deductibles
19 and coinsurance payments shall be based on Medicare allowable
20 fees, not on a provider's billed charges.
21 (c) Medicaid will pay no portion of Medicare
22 deductibles and coinsurance when payment that Medicare has
23 made for the service equals or exceeds what Medicaid would
24 have paid if it had been the sole payor. The combined payment
25 of Medicare and Medicaid shall not exceed the amount Medicaid
26 would have paid had it been the sole payor. The Legislature
27 finds that there has been confusion regarding the
28 reimbursement for services rendered to dually eligible
29 Medicare beneficiaries. Accordingly, the Legislature clarifies
30 that it has always been the intent of the Legislature before
31 and after 1991 that, in reimbursing in accordance with fees
32
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 established by Title XVIII for premiums, deductibles, and
2 coinsurance for Medicare services rendered by physicians to
3 Medicaid eligible persons, physicians be reimbursed at the
4 lesser of the amount billed by the physician or the Medicaid
5 maximum allowable fee established by the Agency for Health
6 Care Administration, as is permitted by federal law. It has
7 never been the intent of the Legislature with regard to such
8 services rendered by physicians that Medicaid be required to
9 provide any payment for deductibles, coinsurance, or
10 copayments for Medicare cost sharing, or any expenses incurred
11 relating thereto, in excess of the payment amount provided for
12 under the State Medicaid plan for such service. This payment
13 methodology is applicable even in those situations in which
14 the payment for Medicare cost sharing for a qualified Medicare
15 beneficiary with respect to an item or service is reduced or
16 eliminated. This expression of the Legislature is in
17 clarification of existing law and shall apply to payment for,
18 and with respect to provider agreements with respect to, items
19 or services furnished on or after the effective date of this
20 act. This paragraph applies to payment by Medicaid for items
21 and services furnished before the effective date of this act
22 if such payment is the subject of a lawsuit that is based on
23 the provisions of this section, and that is pending as of, or
24 is initiated after, the effective date of this act.
25 (d) Notwithstanding paragraphs (a)-(c):
26 1. Medicaid payments for Nursing Home Medicare part A
27 coinsurance shall be the lesser of the Medicare coinsurance
28 amount or the Medicaid nursing home per diem rate.
29 2. Medicaid shall pay all deductibles and coinsurance
30 for Medicare-eligible recipients receiving freestanding end
31 stage renal dialysis center services.
33
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 3. Medicaid payments for general hospital inpatient
2 services shall be limited to the Medicare deductible per spell
3 of illness. Medicaid shall make no payment toward coinsurance
4 for Medicare general hospital inpatient services.
5 4. Medicaid shall pay all deductibles and coinsurance
6 for Medicare emergency transportation services provided by
7 ambulances licensed pursuant to chapter 401.
8 (14) A provider of prescribed drugs shall be
9 reimbursed the least of the amount billed by the provider, the
10 provider's usual and customary charge, or the Medicaid maximum
11 allowable fee established by the agency, plus a dispensing
12 fee. The agency is directed to implement a variable dispensing
13 fee for payments for prescribed medicines while ensuring
14 continued access for Medicaid recipients. The variable
15 dispensing fee may be based upon, but not limited to, either
16 or both the volume of prescriptions dispensed by a specific
17 pharmacy provider, the volume of prescriptions dispensed to an
18 individual recipient, and dispensing of preferred-drug-list
19 products. The agency shall increase the pharmacy dispensing
20 fee authorized by statute and in the annual General
21 Appropriations Act by $0.50 for the dispensing of a Medicaid
22 preferred-drug-list product and reduce the pharmacy dispensing
23 fee by $0.50 for the dispensing of a Medicaid product that is
24 not included on the preferred-drug list. The agency is
25 authorized to limit reimbursement for prescribed medicine in
26 order to comply with any limitations or directions provided
27 for in the General Appropriations Act, which may include
28 implementing a prospective or concurrent utilization review
29 program.
30 (15) A provider of primary care case management
31 services rendered pursuant to a federally approved waiver
34
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 shall be reimbursed by payment of a fixed, prepaid monthly sum
2 for each Medicaid recipient enrolled with the provider.
3 (16) A provider of rural health clinic services and
4 federally qualified health center services shall be reimbursed
5 a rate per visit based on total reasonable costs of the
6 clinic, as determined by the agency in accordance with federal
7 regulations.
8 (17) A provider of targeted case management services
9 shall be reimbursed pursuant to an established fee, except
10 where the Federal Government requires a public provider be
11 reimbursed on the basis of average actual costs.
12 (18) Unless otherwise provided for in the General
13 Appropriations Act, a provider of transportation services
14 shall be reimbursed the lesser of the amount billed by the
15 provider or the Medicaid maximum allowable fee established by
16 the agency, except when the agency has entered into a direct
17 contract with the provider, or with a community transportation
18 coordinator, for the provision of an all-inclusive service, or
19 when services are provided pursuant to an agreement negotiated
20 between the agency and the provider. The agency, as provided
21 for in s. 427.0135, shall purchase transportation services
22 through the community coordinated transportation system, if
23 available, unless the agency determines a more cost-effective
24 method for Medicaid clients. Nothing in this subsection shall
25 be construed to limit or preclude the agency from contracting
26 for services using a prepaid capitation rate or from
27 establishing maximum fee schedules, individualized
28 reimbursement policies by provider type, negotiated fees,
29 prior authorization, competitive bidding, increased use of
30 mass transit, or any other mechanism that the agency considers
31 efficient and effective for the purchase of services on behalf
35
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 of Medicaid clients, including implementing a transportation
2 eligibility process. The agency shall not be required to
3 contract with any community transportation coordinator or
4 transportation operator that has been determined by the
5 agency, the Department of Legal Affairs Medicaid Fraud Control
6 Unit, or any other state or federal agency to have engaged in
7 any abusive or fraudulent billing activities. The agency is
8 authorized to competitively procure transportation services or
9 make other changes necessary to secure approval of federal
10 waivers needed to permit federal financing of Medicaid
11 transportation services at the service matching rate rather
12 than the administrative matching rate.
13 (19) County health department services may be
14 reimbursed a rate per visit based on total reasonable costs of
15 the clinic, as determined by the agency in accordance with
16 federal regulations under the authority of 42 C.F.R. s.
17 431.615.
18 (20) A renal dialysis facility that provides dialysis
19 services under s. 409.906(9) must be reimbursed the lesser of
20 the amount billed by the provider, the provider's usual and
21 customary charge, or the maximum allowable fee established by
22 the agency, whichever amount is less.
23 (21) The agency shall reimburse school districts which
24 certify the state match pursuant to ss. 236.0812 and 409.9071
25 for the federal portion of the school district's allowable
26 costs to deliver the services, based on the reimbursement
27 schedule. The school district shall determine the costs for
28 delivering services as authorized in ss. 236.0812 and 409.9071
29 for which the state match will be certified. Reimbursement of
30 school-based providers is contingent on such providers being
31 enrolled as Medicaid providers and meeting the qualifications
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 contained in 42 C.F.R. s. 440.110, unless otherwise waived by
2 the federal Health Care Financing Administration. Speech
3 therapy providers who are certified through the Department of
4 Education pursuant to rule 6A-4.0176, Florida Administrative
5 Code, are eligible for reimbursement for services that are
6 provided on school premises. Any employee of the school
7 district who has been fingerprinted and has received a
8 criminal background check in accordance with Department of
9 Education rules and guidelines shall be exempt from any agency
10 requirements relating to criminal background checks.
11 (22) The agency shall request and implement Medicaid
12 waivers from the federal Health Care Financing Administration
13 to advance and treat a portion of the Medicaid nursing home
14 per diem as capital for creating and operating a
15 risk-retention group for self-insurance purposes, consistent
16 with federal and state laws and rules.
17 Section 13. Paragraph (b) of subsection (7) of section
18 409.910, Florida Statutes, is amended to read:
19 409.910 Responsibility for payments on behalf of
20 Medicaid-eligible persons when other parties are liable.--
21 (7) The agency shall recover the full amount of all
22 medical assistance provided by Medicaid on behalf of the
23 recipient to the full extent of third-party benefits.
24 (b) Upon receipt of any recovery or other collection
25 pursuant to this section, the agency shall distribute the
26 amount collected as follows:
27 1. To itself, an amount equal to the state Medicaid
28 expenditures for the recipient plus any incentive payment made
29 in accordance with paragraph (14)(a). From this share the
30 agency shall credit a county on its county billing invoice the
31 county's proportionate share of Medicaid third-party
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 recoveries in the areas of estate recoveries and casualty
2 claims, minus the agency's cost of recovering the third-party
3 payments, based on the county's percentage of the sum of total
4 county billing divided by total Medicaid expenditures.
5 However, if a county has been billed for its participation but
6 has not paid the amount due, the agency shall offset that
7 amount and notify the county of the amount of the offset. If
8 the county has divided its financial responsibility between
9 the county and a special taxing district or authority as
10 contemplated in s. 409.915(6), the county must proportionately
11 divide any refund or offset in accordance with the proration
12 that it has established.
13 2. To the Federal Government, the federal share of the
14 state Medicaid expenditures minus any incentive payment made
15 in accordance with paragraph (14)(a) and federal law, and
16 minus any other amount permitted by federal law to be
17 deducted.
18 3. To the recipient, after deducting any known amounts
19 owed to the agency for any related medical assistance or to
20 health care providers, any remaining amount. This amount shall
21 be treated as income or resources in determining eligibility
22 for Medicaid.
23
24 The provisions of this subsection do not apply to any proceeds
25 received by the state, or any agency thereof, pursuant to a
26 final order, judgment, or settlement agreement, in any matter
27 in which the state asserts claims brought on its own behalf,
28 and not as a subrogee of a recipient, or under other theories
29 of liability. The provisions of this subsection do not apply
30 to any proceeds received by the state, or an agency thereof,
31 pursuant to a final order, judgment, or settlement agreement,
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 in any matter in which the state asserted both claims as a
2 subrogee and additional claims, except as to those sums
3 specifically identified in the final order, judgment, or
4 settlement agreement as reimbursements to the recipient as
5 expenditures for the named recipient on the subrogation claim.
6 Section 14. Paragraph (g) of subsection (3) and
7 paragraph (c) of subsection (37) of section 409.912, Florida
8 Statutes, as amended by sections 8 and 9 of chapter 2001-377,
9 Laws of Florida, are amended to read:
10 409.912 Cost-effective purchasing of health care.--The
11 agency shall purchase goods and services for Medicaid
12 recipients in the most cost-effective manner consistent with
13 the delivery of quality medical care. The agency shall
14 maximize the use of prepaid per capita and prepaid aggregate
15 fixed-sum basis services when appropriate and other
16 alternative service delivery and reimbursement methodologies,
17 including competitive bidding pursuant to s. 287.057, designed
18 to facilitate the cost-effective purchase of a case-managed
19 continuum of care. The agency shall also require providers to
20 minimize the exposure of recipients to the need for acute
21 inpatient, custodial, and other institutional care and the
22 inappropriate or unnecessary use of high-cost services. The
23 agency may establish prior authorization requirements for
24 certain populations of Medicaid beneficiaries, certain drug
25 classes, or particular drugs to prevent fraud, abuse, overuse,
26 and possible dangerous drug interactions. The Pharmaceutical
27 and Therapeutics Committee shall make recommendations to the
28 agency on drugs for which prior authorization is required. The
29 agency shall inform the Pharmaceutical and Therapeutics
30 Committee of its decisions regarding drugs subject to prior
31 authorization.
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (3) The agency may contract with:
2 (g) Children's provider networks that provide care
3 coordination and care management for Medicaid-eligible
4 pediatric patients, primary care, authorization of specialty
5 care, and other urgent and emergency care through organized
6 providers designed to service Medicaid eligibles under age 18
7 and pediatric emergency departments' diversion programs. The
8 networks shall provide after-hour operations, including
9 evening and weekend hours, to promote, when appropriate, the
10 use of the children's networks rather than hospital emergency
11 departments.
12 (37)
13 (c) The agency shall submit quarterly reports a report
14 to the Governor, the President of the Senate, and the Speaker
15 of the House of Representatives which by January 15 of each
16 year. The report must include, but need not be limited to, the
17 progress made in implementing this subsection and its Medicaid
18 cost-containment measures and their effect on Medicaid
19 prescribed-drug expenditures.
20 Section 15. Subsection (7) of section 409.9116,
21 Florida Statutes, is amended to read:
22 409.9116 Disproportionate share/financial assistance
23 program for rural hospitals.--In addition to the payments made
24 under s. 409.911, the Agency for Health Care Administration
25 shall administer a federally matched disproportionate share
26 program and a state-funded financial assistance program for
27 statutory rural hospitals. The agency shall make
28 disproportionate share payments to statutory rural hospitals
29 that qualify for such payments and financial assistance
30 payments to statutory rural hospitals that do not qualify for
31 disproportionate share payments. The disproportionate share
40
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 program payments shall be limited by and conform with federal
2 requirements. Funds shall be distributed quarterly in each
3 fiscal year for which an appropriation is made.
4 Notwithstanding the provisions of s. 409.915, counties are
5 exempt from contributing toward the cost of this special
6 reimbursement for hospitals serving a disproportionate share
7 of low-income patients.
8 (7) This section applies only to hospitals that were
9 defined as statutory rural hospitals, or their
10 successor-in-interest hospital, prior to January 1, 2001 July
11 1, 1998. Any additional hospital that is defined as a
12 statutory rural hospital, or its successor-in-interest
13 hospital, on or after January 1, 2001 July 1, 1998, is not
14 eligible for programs under this section unless additional
15 funds are appropriated each fiscal year specifically to the
16 rural hospital disproportionate share and financial assistance
17 programs in an amount necessary to prevent any hospital, or
18 its successor-in-interest hospital, eligible for the programs
19 prior to January 1, 2001 July 1, 1998, from incurring a
20 reduction in payments because of the eligibility of an
21 additional hospital to participate in the programs. A
22 hospital, or its successor-in-interest hospital, which
23 received funds pursuant to this section before January 1, 2001
24 July 1, 1998, and which qualifies under s. 395.602(2)(e),
25 shall be included in the programs under this section and is
26 not required to seek additional appropriations under this
27 subsection.
28 Section 16. Paragraphs (f) and (k) of subsection (2)
29 of section 409.9122, Florida Statutes, as amended by section
30 11 of chapter 2001-377, Laws of Florida, are amended to read:
31 409.9122 Mandatory Medicaid managed care enrollment;
41
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 programs and procedures.--
2 (2)
3 (f) When a Medicaid recipient does not choose a
4 managed care plan or MediPass provider, the agency shall
5 assign the Medicaid recipient to a managed care plan or
6 MediPass provider. Medicaid recipients who are subject to
7 mandatory assignment but who fail to make a choice shall be
8 assigned to managed care plans or provider service networks
9 until an equal enrollment of 45 50 percent in MediPass and 55
10 50 percent in managed care plans is achieved. Once that equal
11 enrollment is achieved, the assignments shall be divided in
12 order to maintain an equal enrollment in MediPass and managed
13 care plans which is in a 45 percent and 55 percent proportion,
14 respectively. Thereafter, assignment of Medicaid recipients
15 who fail to make a choice shall be based proportionally on the
16 preferences of recipients who have made a choice in the
17 previous period. Such proportions shall be revised at least
18 quarterly to reflect an update of the preferences of Medicaid
19 recipients. The agency shall also disproportionately assign
20 Medicaid-eligible children in families who are required to but
21 have failed to make a choice of managed care plan or MediPass
22 for their child and who are to be assigned to the MediPass
23 program or managed care plans to children's networks as
24 described in s. 409.912(3)(g) and where available. The
25 disproportionate assignment of children to children's networks
26 shall be made until the agency has determined that the
27 children's networks have sufficient numbers to be economically
28 operated. For purposes of this section paragraph, when
29 referring to assignment, the term "managed care plans"
30 includes health maintenance organizations, exclusive provider
31 organizations, provider service networks, minority physician
42
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 networks, children's medical service networks, and pediatric
2 emergency department diversion programs authorized by this
3 chapter or the General Appropriations Act. When making
4 assignments, the agency shall take into account the following
5 criteria:
6 1. A managed care plan has sufficient network capacity
7 to meet the need of members.
8 2. The managed care plan or MediPass has previously
9 enrolled the recipient as a member, or one of the managed care
10 plan's primary care providers or MediPass providers has
11 previously provided health care to the recipient.
12 3. The agency has knowledge that the member has
13 previously expressed a preference for a particular managed
14 care plan or MediPass provider as indicated by Medicaid
15 fee-for-service claims data, but has failed to make a choice.
16 4. The managed care plan's or MediPass primary care
17 providers are geographically accessible to the recipient's
18 residence.
19 (k) When a Medicaid recipient does not choose a
20 managed care plan or MediPass provider, the agency shall
21 assign the Medicaid recipient to a managed care plan, except
22 in those counties in which there are fewer than two managed
23 care plans accepting Medicaid enrollees, in which case
24 assignment shall be to a managed care plan or a MediPass
25 provider. Medicaid recipients in counties with fewer than two
26 managed care plans accepting Medicaid enrollees who are
27 subject to mandatory assignment but who fail to make a choice
28 shall be assigned to managed care plans until an equal
29 enrollment of 45 50 percent in MediPass and provider service
30 networks and 55 50 percent in managed care plans is achieved.
31 Once that equal enrollment is achieved, the assignments shall
43
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 be divided in order to maintain an equal enrollment in
2 MediPass and managed care plans which is in a 45 percent and
3 55 percent proportion, respectively. When making assignments,
4 the agency shall take into account the following criteria:
5 1. A managed care plan has sufficient network capacity
6 to meet the need of members.
7 2. The managed care plan or MediPass has previously
8 enrolled the recipient as a member, or one of the managed care
9 plan's primary care providers or MediPass providers has
10 previously provided health care to the recipient.
11 3. The agency has knowledge that the member has
12 previously expressed a preference for a particular managed
13 care plan or MediPass provider as indicated by Medicaid
14 fee-for-service claims data, but has failed to make a choice.
15 4. The managed care plan's or MediPass primary care
16 providers are geographically accessible to the recipient's
17 residence.
18 5. The agency has authority to make mandatory
19 assignments based on quality of service and performance of
20 managed care plans.
21 Section 17. Section 409.913, Florida Statutes, as
22 amended by section 12 of chapter 2001-377, Laws of Florida, is
23 amended to read:
24 409.913 Oversight of the integrity of the Medicaid
25 program.--The agency shall operate a program to oversee the
26 activities of Florida Medicaid recipients, and providers and
27 their representatives, to ensure that fraudulent and abusive
28 behavior and neglect of recipients occur to the minimum extent
29 possible, and to recover overpayments and impose sanctions as
30 appropriate. Beginning January 1, 2003, and each year
31 thereafter, the agency and the Medicaid Fraud Control Unit of
44
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 the Department of Legal Affairs shall submit a joint report to
2 the Legislature documenting the effectiveness of the state's
3 efforts to control Medicaid fraud and abuse and to recover
4 Medicaid overpayments during the previous fiscal year. The
5 report must describe the number of cases opened and
6 investigated each year; the sources of the cases opened; the
7 disposition of the cases closed each year; the amount of
8 overpayments alleged in preliminary and final audit letters;
9 the number and amount of fines or penalties imposed; any
10 reductions in overpayment amounts negotiated in settlement
11 agreements or by other means; the amount of final agency
12 determinations of overpayments; the amount deducted from
13 federal claiming as a result of overpayments; the amount of
14 overpayments recovered each year; the amount of cost of
15 investigation recovered each year; the average length of time
16 to collect from the time the case was opened until the
17 overpayment is paid in full; the amount determined as
18 uncollectible and the portion of the uncollectible amount
19 subsequently reclaimed from the Federal Government; the number
20 of providers, by type, that are terminated from participation
21 in the Medicaid program as a result of fraud and abuse; and
22 all costs associated with discovering and prosecuting cases of
23 Medicaid overpayments and making recoveries in such cases. The
24 report must also document actions taken to prevent
25 overpayments and the number of providers prevented from
26 enrolling in or reenrolling in the Medicaid program as a
27 result of documented Medicaid fraud and abuse and must
28 recommend changes necessary to prevent or recover
29 overpayments. For the 2001-2002 fiscal year, the agency shall
30 prepare a report that contains as much of this information as
31 is available to it.
45
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (1) For the purposes of this section, the term:
2 (a) "Abuse" means:
3 1. Provider practices that are inconsistent with
4 generally accepted business or medical practices and that
5 result in an unnecessary cost to the Medicaid program or in
6 reimbursement for goods or services that are not medically
7 necessary or that fail to meet professionally recognized
8 standards for health care.
9 2. Recipient practices that result in unnecessary cost
10 to the Medicaid program.
11 (b) "Complaint" means an allegation that fraud, abuse
12 or an overpayment has occurred.
13 (c)(b) "Fraud" means an intentional deception or
14 misrepresentation made by a person with the knowledge that the
15 deception results in unauthorized benefit to herself or
16 himself or another person. The term includes any act that
17 constitutes fraud under applicable federal or state law.
18 (d)(c) "Medical necessity" or "medically necessary"
19 means any goods or services necessary to palliate the effects
20 of a terminal condition, or to prevent, diagnose, correct,
21 cure, alleviate, or preclude deterioration of a condition that
22 threatens life, causes pain or suffering, or results in
23 illness or infirmity, which goods or services are provided in
24 accordance with generally accepted standards of medical
25 practice. For purposes of determining Medicaid reimbursement,
26 the agency is the final arbiter of medical necessity.
27 Determinations of medical necessity must be made by a licensed
28 physician employed by or under contract with the agency and
29 must be based upon information available at the time the goods
30 or services are provided.
31 (e)(d) "Overpayment" includes any amount that is not
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 authorized to be paid by the Medicaid program whether paid as
2 a result of inaccurate or improper cost reporting, improper
3 claiming, unacceptable practices, fraud, abuse, or mistake.
4 (f)(e) "Person" means any natural person, corporation,
5 partnership, association, clinic, group, or other entity,
6 whether or not such person is enrolled in the Medicaid program
7 or is a provider of health care.
8 (2) The agency shall conduct, or cause to be conducted
9 by contract or otherwise, reviews, investigations, analyses,
10 audits, or any combination thereof, to determine possible
11 fraud, abuse, overpayment, or recipient neglect in the
12 Medicaid program and shall report the findings of any
13 overpayments in audit reports as appropriate.
14 (3) The agency may conduct, or may contract for,
15 prepayment review of provider claims to ensure cost-effective
16 purchasing, billing, and provision of care to Medicaid
17 recipients. Such prepayment reviews may be conducted as
18 determined appropriate by the agency, without any suspicion or
19 allegation of fraud, abuse, or neglect.
20 (4) Any suspected criminal violation identified by the
21 agency must be referred to the Medicaid Fraud Control Unit of
22 the Office of the Attorney General for investigation. The
23 agency and the Attorney General shall enter into a memorandum
24 of understanding, which must include, but need not be limited
25 to, a protocol for regularly sharing information and
26 coordinating casework. The protocol must establish a
27 procedure for the referral by the agency of cases involving
28 suspected Medicaid fraud to the Medicaid Fraud Control Unit
29 for investigation, and the return to the agency of those cases
30 where investigation determines that administrative action by
31 the agency is appropriate. Offices of the Medicaid program
47
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 integrity program and the Medicaid Fraud Control Unit of the
2 Department of Legal Affairs, shall, to the extent possible, be
3 collocated. The agency and the Department of Legal Affairs
4 shall periodically conduct joint training and other joint
5 activities designed to increase communication and coordination
6 in recovering overpayments.
7 (5) A Medicaid provider is subject to having goods and
8 services that are paid for by the Medicaid program reviewed by
9 an appropriate peer-review organization designated by the
10 agency. The written findings of the applicable peer-review
11 organization are admissible in any court or administrative
12 proceeding as evidence of medical necessity or the lack
13 thereof.
14 (6) Any notice required to be given to a provider
15 under this section is presumed to be sufficient notice if sent
16 to the address last shown on the provider enrollment file. It
17 is the responsibility of the provider to furnish and keep the
18 agency informed of the provider's current address. United
19 States Postal Service proof of mailing or certified or
20 registered mailing of such notice to the provider at the
21 address shown on the provider enrollment file constitutes
22 sufficient proof of notice. Any notice required to be given to
23 the agency by this section must be sent to the agency at an
24 address designated by rule.
25 (7) When presenting a claim for payment under the
26 Medicaid program, a provider has an affirmative duty to
27 supervise the provision of, and be responsible for, goods and
28 services claimed to have been provided, to supervise and be
29 responsible for preparation and submission of the claim, and
30 to present a claim that is true and accurate and that is for
31 goods and services that:
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (a) Have actually been furnished to the recipient by
2 the provider prior to submitting the claim.
3 (b) Are Medicaid-covered goods or services that are
4 medically necessary.
5 (c) Are of a quality comparable to those furnished to
6 the general public by the provider's peers.
7 (d) Have not been billed in whole or in part to a
8 recipient or a recipient's responsible party, except for such
9 copayments, coinsurance, or deductibles as are authorized by
10 the agency.
11 (e) Are provided in accord with applicable provisions
12 of all Medicaid rules, regulations, handbooks, and policies
13 and in accordance with federal, state, and local law.
14 (f) Are documented by records made at the time the
15 goods or services were provided, demonstrating the medical
16 necessity for the goods or services rendered. Medicaid goods
17 or services are excessive or not medically necessary unless
18 both the medical basis and the specific need for them are
19 fully and properly documented in the recipient's medical
20 record.
21 (8) A Medicaid provider shall retain medical,
22 professional, financial, and business records pertaining to
23 services and goods furnished to a Medicaid recipient and
24 billed to Medicaid for a period of 5 years after the date of
25 furnishing such services or goods. The agency may investigate,
26 review, or analyze such records, which must be made available
27 during normal business hours. However, 24-hour notice must be
28 provided if patient treatment would be disrupted. The provider
29 is responsible for furnishing to the agency, and keeping the
30 agency informed of the location of, the provider's
31 Medicaid-related records. The authority of the agency to
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 obtain Medicaid-related records from a provider is neither
2 curtailed nor limited during a period of litigation between
3 the agency and the provider.
4 (9) Payments for the services of billing agents or
5 persons participating in the preparation of a Medicaid claim
6 shall not be based on amounts for which they bill nor based on
7 the amount a provider receives from the Medicaid program.
8 (10) The agency may require repayment for
9 inappropriate, medically unnecessary, or excessive goods or
10 services from the person furnishing them, the person under
11 whose supervision they were furnished, or the person causing
12 them to be furnished.
13 (11) The complaint and all information obtained
14 pursuant to an investigation of a Medicaid provider, or the
15 authorized representative or agent of a provider, relating to
16 an allegation of fraud, abuse, or neglect are confidential and
17 exempt from the provisions of s. 119.07(1):
18 (a) Until the agency takes final agency action with
19 respect to the provider and requires repayment of any
20 overpayment, or imposes an administrative sanction;
21 (b) Until the Attorney General refers the case for
22 criminal prosecution;
23 (c) Until 10 days after the complaint is determined
24 without merit; or
25 (d) At all times if the complaint or information is
26 otherwise protected by law.
27 (12) The agency may terminate participation of a
28 Medicaid provider in the Medicaid program and may seek civil
29 remedies or impose other administrative sanctions against a
30 Medicaid provider, if the provider has been:
31 (a) Convicted of a criminal offense related to the
50
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 delivery of any health care goods or services, including the
2 performance of management or administrative functions relating
3 to the delivery of health care goods or services;
4 (b) Convicted of a criminal offense under federal law
5 or the law of any state relating to the practice of the
6 provider's profession; or
7 (c) Found by a court of competent jurisdiction to have
8 neglected or physically abused a patient in connection with
9 the delivery of health care goods or services.
10 (13) If the provider has been suspended or terminated
11 from participation in the Medicaid program or the Medicare
12 program by the Federal Government or any state, the agency
13 must immediately suspend or terminate, as appropriate, the
14 provider's participation in the Florida Medicaid program for a
15 period no less than that imposed by the Federal Government or
16 any other state, and may not enroll such provider in the
17 Florida Medicaid program while such foreign suspension or
18 termination remains in effect. This sanction is in addition
19 to all other remedies provided by law.
20 (14) The agency may seek any remedy provided by law,
21 including, but not limited to, the remedies provided in
22 subsections (12) and (15) and s. 812.035, if:
23 (a) The provider's license has not been renewed, or
24 has been revoked, suspended, or terminated, for cause, by the
25 licensing agency of any state;
26 (b) The provider has failed to make available or has
27 refused access to Medicaid-related records to an auditor,
28 investigator, or other authorized employee or agent of the
29 agency, the Attorney General, a state attorney, or the Federal
30 Government;
31 (c) The provider has not furnished or has failed to
51
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 make available such Medicaid-related records as the agency has
2 found necessary to determine whether Medicaid payments are or
3 were due and the amounts thereof;
4 (d) The provider has failed to maintain medical
5 records made at the time of service, or prior to service if
6 prior authorization is required, demonstrating the necessity
7 and appropriateness of the goods or services rendered;
8 (e) The provider is not in compliance with provisions
9 of Medicaid provider publications that have been adopted by
10 reference as rules in the Florida Administrative Code; with
11 provisions of state or federal laws, rules, or regulations;
12 with provisions of the provider agreement between the agency
13 and the provider; or with certifications found on claim forms
14 or on transmittal forms for electronically submitted claims
15 that are submitted by the provider or authorized
16 representative, as such provisions apply to the Medicaid
17 program;
18 (f) The provider or person who ordered or prescribed
19 the care, services, or supplies has furnished, or ordered the
20 furnishing of, goods or services to a recipient which are
21 inappropriate, unnecessary, excessive, or harmful to the
22 recipient or are of inferior quality;
23 (g) The provider has demonstrated a pattern of failure
24 to provide goods or services that are medically necessary;
25 (h) The provider or an authorized representative of
26 the provider, or a person who ordered or prescribed the goods
27 or services, has submitted or caused to be submitted false or
28 a pattern of erroneous Medicaid claims that have resulted in
29 overpayments to a provider or that exceed those to which the
30 provider was entitled under the Medicaid program;
31 (i) The provider or an authorized representative of
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 the provider, or a person who has ordered or prescribed the
2 goods or services, has submitted or caused to be submitted a
3 Medicaid provider enrollment application, a request for prior
4 authorization for Medicaid services, a drug exception request,
5 or a Medicaid cost report that contains materially false or
6 incorrect information;
7 (j) The provider or an authorized representative of
8 the provider has collected from or billed a recipient or a
9 recipient's responsible party improperly for amounts that
10 should not have been so collected or billed by reason of the
11 provider's billing the Medicaid program for the same service;
12 (k) The provider or an authorized representative of
13 the provider has included in a cost report costs that are not
14 allowable under a Florida Title XIX reimbursement plan, after
15 the provider or authorized representative had been advised in
16 an audit exit conference or audit report that the costs were
17 not allowable;
18 (l) The provider is charged by information or
19 indictment with fraudulent billing practices. The sanction
20 applied for this reason is limited to suspension of the
21 provider's participation in the Medicaid program for the
22 duration of the indictment unless the provider is found guilty
23 pursuant to the information or indictment;
24 (m) The provider or a person who has ordered, or
25 prescribed the goods or services is found liable for negligent
26 practice resulting in death or injury to the provider's
27 patient;
28 (n) The provider fails to demonstrate that it had
29 available during a specific audit or review period sufficient
30 quantities of goods, or sufficient time in the case of
31 services, to support the provider's billings to the Medicaid
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Amendment No. ___ Barcode 934922
1 program;
2 (o) The provider has failed to comply with the notice
3 and reporting requirements of s. 409.907; or
4 (p) The agency has received reliable information of
5 patient abuse or neglect or of any act prohibited by s.
6 409.920; or.
7 (q) The provider has failed to comply with an
8 agreed-upon repayment schedule.
9 (15) The agency shall may impose any of the following
10 sanctions or disincentives on a provider or a person for any
11 of the acts described in subsection (14):
12 (a) Suspension for a specific period of time of not
13 more than 1 year.
14 (b) Termination for a specific period of time of from
15 more than 1 year to 20 years.
16 (c) Imposition of a fine of up to $5,000 for each
17 violation. Each day that an ongoing violation continues, such
18 as refusing to furnish Medicaid-related records or refusing
19 access to records, is considered, for the purposes of this
20 section, to be a separate violation. Each instance of
21 improper billing of a Medicaid recipient; each instance of
22 including an unallowable cost on a hospital or nursing home
23 Medicaid cost report after the provider or authorized
24 representative has been advised in an audit exit conference or
25 previous audit report of the cost unallowability; each
26 instance of furnishing a Medicaid recipient goods or
27 professional services that are inappropriate or of inferior
28 quality as determined by competent peer judgment; each
29 instance of knowingly submitting a materially false or
30 erroneous Medicaid provider enrollment application, request
31 for prior authorization for Medicaid services, drug exception
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 request, or cost report; each instance of inappropriate
2 prescribing of drugs for a Medicaid recipient as determined by
3 competent peer judgment; and each false or erroneous Medicaid
4 claim leading to an overpayment to a provider is considered,
5 for the purposes of this section, to be a separate violation.
6 (d) Immediate suspension, if the agency has received
7 information of patient abuse or neglect or of any act
8 prohibited by s. 409.920. Upon suspension, the agency must
9 issue an immediate final order under s. 120.569(2)(n).
10 (e) A fine, not to exceed $10,000, for a violation of
11 paragraph (14)(i).
12 (f) Imposition of liens against provider assets,
13 including, but not limited to, financial assets and real
14 property, not to exceed the amount of fines or recoveries
15 sought, upon entry of an order determining that such moneys
16 are due or recoverable.
17 (g) Prepayment reviews of claims for a specified
18 period of time.
19 (h) Comprehensive follow-up reviews of providers every
20 6 months to ensure that they are billing Medicaid correctly.
21 (i) Corrective-action plans that would remain in
22 effect for providers for up to 3 years and that would be
23 monitored by the agency every 6 months while in effect.
24 (j)(g) Other remedies as permitted by law to effect
25 the recovery of a fine or overpayment.
26
27 The Secretary of Health Care Administration may make a
28 determination that imposition of a sanction or disincentive is
29 not in the best interest of the Medicaid program, in which
30 case a sanction or disincentive shall not be imposed.
31 (16) In determining the appropriate administrative
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Amendment No. ___ Barcode 934922
1 sanction to be applied, or the duration of any suspension or
2 termination, the agency shall consider:
3 (a) The seriousness and extent of the violation or
4 violations.
5 (b) Any prior history of violations by the provider
6 relating to the delivery of health care programs which
7 resulted in either a criminal conviction or in administrative
8 sanction or penalty.
9 (c) Evidence of continued violation within the
10 provider's management control of Medicaid statutes, rules,
11 regulations, or policies after written notification to the
12 provider of improper practice or instance of violation.
13 (d) The effect, if any, on the quality of medical care
14 provided to Medicaid recipients as a result of the acts of the
15 provider.
16 (e) Any action by a licensing agency respecting the
17 provider in any state in which the provider operates or has
18 operated.
19 (f) The apparent impact on access by recipients to
20 Medicaid services if the provider is suspended or terminated,
21 in the best judgment of the agency.
22
23 The agency shall document the basis for all sanctioning
24 actions and recommendations.
25 (17) The agency may take action to sanction, suspend,
26 or terminate a particular provider working for a group
27 provider, and may suspend or terminate Medicaid participation
28 at a specific location, rather than or in addition to taking
29 action against an entire group.
30 (18) The agency shall establish a process for
31 conducting followup reviews of a sampling of providers who
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 have a history of overpayment under the Medicaid program.
2 This process must consider the magnitude of previous fraud or
3 abuse and the potential effect of continued fraud or abuse on
4 Medicaid costs.
5 (19) In making a determination of overpayment to a
6 provider, the agency must use accepted and valid auditing,
7 accounting, analytical, statistical, or peer-review methods,
8 or combinations thereof. Appropriate statistical methods may
9 include, but are not limited to, sampling and extension to the
10 population, parametric and nonparametric statistics, tests of
11 hypotheses, and other generally accepted statistical methods.
12 Appropriate analytical methods may include, but are not
13 limited to, reviews to determine variances between the
14 quantities of products that a provider had on hand and
15 available to be purveyed to Medicaid recipients during the
16 review period and the quantities of the same products paid for
17 by the Medicaid program for the same period, taking into
18 appropriate consideration sales of the same products to
19 non-Medicaid customers during the same period. In meeting its
20 burden of proof in any administrative or court proceeding, the
21 agency may introduce the results of such statistical methods
22 as evidence of overpayment.
23 (20) When making a determination that an overpayment
24 has occurred, the agency shall prepare and issue an audit
25 report to the provider showing the calculation of
26 overpayments.
27 (21) The audit report, supported by agency work
28 papers, showing an overpayment to a provider constitutes
29 evidence of the overpayment. A provider may not present or
30 elicit testimony, either on direct examination or
31 cross-examination in any court or administrative proceeding,
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Amendment No. ___ Barcode 934922
1 regarding the purchase or acquisition by any means of drugs,
2 goods, or supplies; sales or divestment by any means of drugs,
3 goods, or supplies; or inventory of drugs, goods, or supplies,
4 unless such acquisition, sales, divestment, or inventory is
5 documented by written invoices, written inventory records, or
6 other competent written documentary evidence maintained in the
7 normal course of the provider's business. Notwithstanding the
8 applicable rules of discovery, all documentation that will be
9 offered as evidence at an administrative hearing on a Medicaid
10 overpayment must be exchanged by all parties at least 14 days
11 before the administrative hearing or must be excluded from
12 consideration.
13 (22)(a) In an audit or investigation of a violation
14 committed by a provider which is conducted pursuant to this
15 section, the agency is entitled to recover all investigative,
16 legal, and expert witness costs if the agency's findings were
17 not contested by the provider or, if contested, the agency
18 ultimately prevailed.
19 (b) The agency has the burden of documenting the
20 costs, which include salaries and employee benefits and
21 out-of-pocket expenses. The amount of costs that may be
22 recovered must be reasonable in relation to the seriousness of
23 the violation and must be set taking into consideration the
24 financial resources, earning ability, and needs of the
25 provider, who has the burden of demonstrating such factors.
26 (c) The provider may pay the costs over a period to be
27 determined by the agency if the agency determines that an
28 extreme hardship would result to the provider from immediate
29 full payment. Any default in payment of costs may be
30 collected by any means authorized by law.
31 (23) If the agency imposes an administrative sanction
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Amendment No. ___ Barcode 934922
1 under this section upon any provider or other person who is
2 regulated by another state entity, the agency shall notify
3 that other entity of the imposition of the sanction. Such
4 notification must include the provider's or person's name and
5 license number and the specific reasons for sanction.
6 (24)(a) The agency may withhold Medicaid payments, in
7 whole or in part, to a provider upon receipt of reliable
8 evidence that the circumstances giving rise to the need for a
9 withholding of payments involve fraud, willful
10 misrepresentation, or abuse under the Medicaid program, or a
11 crime committed while rendering goods or services to Medicaid
12 recipients, pending completion of legal proceedings. If it is
13 determined that fraud, willful misrepresentation, abuse, or a
14 crime did not occur, the payments withheld must be paid to the
15 provider within 14 days after such determination with interest
16 at the rate of 10 percent a year. Any money withheld in
17 accordance with this paragraph shall be placed in a suspended
18 account, readily accessible to the agency, so that any payment
19 ultimately due the provider shall be made within 14 days.
20 (b) Overpayments owed to the agency bear interest at
21 the rate of 10 percent per year from the date of determination
22 of the overpayment by the agency, and payment arrangements
23 must be made at the conclusion of legal proceedings. A
24 provider who does not enter into or adhere to an agreed-upon
25 repayment schedule may be terminated by the agency for
26 nonpayment or partial payment.
27 (c) The agency, upon entry of a final agency order, a
28 judgment or order of a court of competent jurisdiction, or a
29 stipulation or settlement, may collect the moneys owed by all
30 means allowable by law, including, but not limited to,
31 notifying any fiscal intermediary of Medicare benefits that
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 the state has a superior right of payment. Upon receipt of
2 such written notification, the Medicare fiscal intermediary
3 shall remit to the state the sum claimed.
4 (25) The agency may impose administrative sanctions
5 against a Medicaid recipient, or the agency may seek any other
6 remedy provided by law, including, but not limited to, the
7 remedies provided in s. 812.035, if the agency finds that a
8 recipient has engaged in solicitation in violation of s.
9 409.920 or that the recipient has otherwise abused the
10 Medicaid program.
11 (26) When the Agency for Health Care Administration
12 has made a probable cause determination and alleged that an
13 overpayment to a Medicaid provider has occurred, the agency,
14 after notice to the provider, may:
15 (a) Withhold, and continue to withhold during the
16 pendency of an administrative hearing pursuant to chapter 120,
17 any medical assistance reimbursement payments until such time
18 as the overpayment is recovered, unless within 30 days after
19 receiving notice thereof the provider:
20 1. Makes repayment in full; or
21 2. Establishes a repayment plan that is satisfactory
22 to the Agency for Health Care Administration.
23 (b) Withhold, and continue to withhold during the
24 pendency of an administrative hearing pursuant to chapter 120,
25 medical assistance reimbursement payments if the terms of a
26 repayment plan are not adhered to by the provider.
27
28 If a provider requests an administrative hearing pursuant to
29 chapter 120, such hearing must be conducted within 90 days
30 following receipt by the provider of the final audit report,
31 absent exceptionally good cause shown as determined by the
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 administrative law judge or hearing officer. Upon issuance of
2 a final order, the balance outstanding of the amount
3 determined to constitute the overpayment shall become due. Any
4 withholding of payments by the Agency for Health Care
5 Administration pursuant to this section shall be limited so
6 that the monthly medical assistance payment is not reduced by
7 more than 10 percent.
8 (27) Venue for all Medicaid program integrity
9 overpayment cases shall lie in Leon County, at the discretion
10 of the agency.
11 (28) Notwithstanding other provisions of law, the
12 agency and the Medicaid Fraud Control Unit of the Department
13 of Legal Affairs may review a provider's Medicaid-related
14 records in order to determine the total output of a provider's
15 practice to reconcile quantities of goods or services billed
16 to Medicaid against quantities of goods or services used in
17 the provider's total practice.
18 (29) The agency may terminate a provider's
19 participation in the Medicaid program if the provider fails to
20 reimburse an overpayment that has been determined by final
21 order, not subject to further appeal, within 35 days after the
22 date of the final order, unless the provider and the agency
23 have entered into a repayment agreement.
24 (30) If a provider requests an administrative hearing
25 pursuant to chapter 120, such hearing must be conducted within
26 90 days following assignment of an administrative law judge,
27 absent exceptionally good cause shown as determined by the
28 administrative law judge or hearing officer. Upon issuance of
29 a final order, the outstanding balance of the amount
30 determined to constitute the overpayment shall become due. If
31 a provider fails to make payments in full, fails to enter into
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 a satisfactory repayment plan, or fails to comply with the
2 terms of a repayment plan or settlement agreement, the agency
3 may withhold medical-assistance-reimbursement payments until
4 the amount due is paid in full.
5 (31) Duly authorized agents and employees of the
6 agency shall have the power to inspect, during normal business
7 hours, the records of any pharmacy, wholesale establishment,
8 or manufacturer, or any other place in which drugs and medical
9 supplies are manufactured, packed, packaged, made, stored,
10 sold, or kept for sale, for the purpose of verifying the
11 amount of drugs and medical supplies ordered, delivered, or
12 purchased by a provider. The agency shall provide at least 2
13 business days' prior notice of any such inspection. The notice
14 must identify the provider whose records will be inspected,
15 and the inspection shall include only records specifically
16 related to that provider.
17 (32) With respect to recoveries of Medicaid
18 overpayments collected by the agency, by September 30 each
19 year the agency shall credit a county on its county billing
20 invoices for the county's proportionate share of Medicaid
21 overpayments recovered during the previous fiscal year from
22 hospitals for inpatient services and from nursing homes.
23 However, if a county has been billed for its participation but
24 has not paid the amount due, the agency shall offset that
25 amount and notify the county of the amount of the offset. If
26 the county has divided its financial responsibility between
27 the county and a special taxing district or authority as
28 provided in s. 409.915(6), the county must proportionately
29 divide any credit or offset in accordance with the proration
30 that it has established. The credit or offset shall be
31 calculated separately for inpatient and nursing home services
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 as follows:
2 (a) The state share of the amount recovered from
3 hospitals for inpatient services and from nursing homes for
4 which the county has not previously received credit;
5 (b) Less the state share of the agency's cost of
6 recovering such payment; and
7 (c) Multiplied by the total county share. The total
8 county share shall be calculated as the sum of total county
9 billing for inpatient services and nursing home services,
10 respectively, divided by the state share of Medicaid
11 expenditures for inpatient services and nursing home services,
12 respectively.
13
14 The credit given to each county shall be its proportionate
15 share of the total county share calculated under paragraph
16 (c).
17 Section 18. Subsections (7) and (8) of section
18 409.920, Florida Statutes, are amended to read:
19 409.920 Medicaid provider fraud.--
20 (7) The Attorney General shall conduct a statewide
21 program of Medicaid fraud control. To accomplish this purpose,
22 the Attorney General shall:
23 (a) Investigate the possible criminal violation of any
24 applicable state law pertaining to fraud in the administration
25 of the Medicaid program, in the provision of medical
26 assistance, or in the activities of providers of health care
27 under the Medicaid program.
28 (b) Investigate the alleged abuse or neglect of
29 patients in health care facilities receiving payments under
30 the Medicaid program, in coordination with the agency.
31 (c) Investigate the alleged misappropriation of
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 patients' private funds in health care facilities receiving
2 payments under the Medicaid program.
3 (d) Refer to the Office of Statewide Prosecution or
4 the appropriate state attorney all violations indicating a
5 substantial potential for criminal prosecution.
6 (e) Refer to the agency all suspected abusive
7 activities not of a criminal or fraudulent nature.
8 (f) Refer to the agency for collection each instance
9 of overpayment to a provider of health care under the Medicaid
10 program which is discovered during the course of an
11 investigation.
12 (f)(g) Safeguard the privacy rights of all individuals
13 and provide safeguards to prevent the use of patient medical
14 records for any reason beyond the scope of a specific
15 investigation for fraud or abuse, or both, without the
16 patient's written consent.
17 (g) Publicize to state employees and the public the
18 ability of persons to bring suit under the provisions of the
19 Florida False Claims Act and the potential for the persons
20 bring a civil action under the Florida False Claims Act to
21 obtain a monetary award.
22 (8) In carrying out the duties and responsibilities
23 under this section subsection, the Attorney General may:
24 (a) Enter upon the premises of any health care
25 provider, excluding a physician, participating in the Medicaid
26 program to examine all accounts and records that may, in any
27 manner, be relevant in determining the existence of fraud in
28 the Medicaid program, to investigate alleged abuse or neglect
29 of patients, or to investigate alleged misappropriation of
30 patients' private funds. A participating physician is required
31 to make available any accounts or records that may, in any
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 manner, be relevant in determining the existence of fraud in
2 the Medicaid program. The accounts or records of a
3 non-Medicaid patient may not be reviewed by, or turned over
4 to, the Attorney General without the patient's written
5 consent.
6 (b) Subpoena witnesses or materials, including medical
7 records relating to Medicaid recipients, within or outside the
8 state and, through any duly designated employee, administer
9 oaths and affirmations and collect evidence for possible use
10 in either civil or criminal judicial proceedings.
11 (c) Request and receive the assistance of any state
12 attorney or law enforcement agency in the investigation and
13 prosecution of any violation of this section.
14 (d) Seek any civil remedy provided by law, including,
15 but not limited to, the remedies provided in ss.
16 68.081-68.092, s. 812.035, and this chapter.
17 (e) Refer to the agency for collection each instance
18 of overpayment to a provider of health care under the Medicaid
19 program which is discovered during the course of an
20 investigation.
21 Section 19. Paragraph (a) of subsection (1) of section
22 499.012, Florida Statutes, is amended to read:
23 499.012 Wholesale distribution; definitions; permits;
24 general requirements.--
25 (1) As used in this section, the term:
26 (a) "Wholesale distribution" means distribution of
27 prescription drugs to persons other than a consumer or
28 patient, but does not include:
29 1. Any of the following activities, which is not a
30 violation of s. 499.005(21) if such activity is conducted in
31 accordance with s. 499.014:
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Amendment No. ___ Barcode 934922
1 a. The purchase or other acquisition by a hospital or
2 other health care entity that is a member of a group
3 purchasing organization of a prescription drug for its own use
4 from the group purchasing organization or from other hospitals
5 or health care entities that are members of that organization.
6 b. The sale, purchase, or trade of a prescription drug
7 or an offer to sell, purchase, or trade a prescription drug by
8 a charitable organization described in s. 501(c)(3) of the
9 Internal Revenue Code of 1986, as amended and revised, to a
10 nonprofit affiliate of the organization to the extent
11 otherwise permitted by law.
12 c. The sale, purchase, or trade of a prescription drug
13 or an offer to sell, purchase, or trade a prescription drug
14 among hospitals or other health care entities that are under
15 common control. For purposes of this section, "common control"
16 means the power to direct or cause the direction of the
17 management and policies of a person or an organization,
18 whether by ownership of stock, by voting rights, by contract,
19 or otherwise.
20 d. The sale, purchase, trade, or other transfer of a
21 prescription drug from or for any federal, state, or local
22 government agency or any entity eligible to purchase
23 prescription drugs at public health services prices pursuant
24 to Pub. L. No. 102-585, s. 602 to a contract provider or its
25 subcontractor for eligible patients of the agency or entity
26 under the following conditions:
27 (I) The agency or entity must obtain written
28 authorization for the sale, purchase, trade, or other transfer
29 of a prescription drug under this sub-subparagraph from the
30 Secretary of Health or his or her designee.
31 (II) The contract provider or subcontractor must be
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 authorized by law to administer or dispense prescription
2 drugs.
3 (III) In the case of a subcontractor, the agency or
4 entity must be a party to and execute the subcontract.
5 (IV) A contract provider or subcontractor must
6 maintain separate and apart from other prescription drug
7 inventory any prescription drugs of the agency or entity in
8 its possession.
9 (V) The contract provider and subcontractor must
10 maintain and produce immediately for inspection all records of
11 movement or transfer of all the prescription drugs belonging
12 to the agency or entity, including, but not limited to, the
13 records of receipt and disposition of prescription drugs. Each
14 contractor and subcontractor dispensing or administering these
15 drugs must maintain and produce records documenting the
16 dispensing or administration. Records that are required to be
17 maintained include, but are not limited to, a perpetual
18 inventory itemizing drugs received and drugs dispensed by
19 prescription number or administered by patient identifier,
20 which must be submitted to the agency or entity quarterly.
21 (VI) The contract provider or subcontractor may
22 administer or dispense the prescription drugs only to the
23 eligible patients of the agency or entity or must return the
24 prescription drugs for or to the agency or entity. The
25 contract provider or subcontractor must require proof from
26 each person seeking to fill a prescription or obtain treatment
27 that the person is an eligible patient of the agency or entity
28 and must, at a minimum, maintain a copy of this proof as part
29 of the records of the contractor or subcontractor required
30 under sub-sub-subparagraph (V).
31 (VII) The prescription drugs transferred pursuant to
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 this sub-subparagraph may not be billed to Medicaid.
2 (VII)(VIII) In addition to the departmental inspection
3 authority set forth in s. 499.051, the establishment of the
4 contract provider and subcontractor and all records pertaining
5 to prescription drugs subject to this sub-subparagraph shall
6 be subject to inspection by the agency or entity. All records
7 relating to prescription drugs of a manufacturer under this
8 sub-subparagraph shall be subject to audit by the manufacturer
9 of those drugs, without identifying individual patient
10 information.
11 2. Any of the following activities, which is not a
12 violation of s. 499.005(21) if such activity is conducted in
13 accordance with rules established by the department:
14 a. The sale, purchase, or trade of a prescription drug
15 among federal, state, or local government health care entities
16 that are under common control and are authorized to purchase
17 such prescription drug.
18 b. The sale, purchase, or trade of a prescription drug
19 or an offer to sell, purchase, or trade a prescription drug
20 for emergency medical reasons. For purposes of this
21 sub-subparagraph, the term "emergency medical reasons"
22 includes transfers of prescription drugs by a retail pharmacy
23 to another retail pharmacy to alleviate a temporary shortage.
24 c. The transfer of a prescription drug acquired by a
25 medical director on behalf of a licensed emergency medical
26 services provider to that emergency medical services provider
27 and its transport vehicles for use in accordance with the
28 provider's license under chapter 401.
29 d. The revocation of a sale or the return of a
30 prescription drug to the person's prescription drug wholesale
31 supplier.
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Amendment No. ___ Barcode 934922
1 e. The donation of a prescription drug by a health
2 care entity to a charitable organization that has been granted
3 an exemption under s. 501(c)(3) of the Internal Revenue Code
4 of 1986, as amended, and that is authorized to possess
5 prescription drugs.
6 f. The transfer of a prescription drug by a person
7 authorized to purchase or receive prescription drugs to a
8 person licensed or permitted to handle reverse distributions
9 or destruction under the laws of the jurisdiction in which the
10 person handling the reverse distribution or destruction
11 receives the drug.
12 3. The distribution of prescription drug samples by
13 manufacturers' representatives or distributors'
14 representatives conducted in accordance with s. 499.028.
15 4. The sale, purchase, or trade of blood and blood
16 components intended for transfusion. As used in this
17 subparagraph, the term "blood" means whole blood collected
18 from a single donor and processed either for transfusion or
19 further manufacturing, and the term "blood components" means
20 that part of the blood separated by physical or mechanical
21 means.
22 5. The lawful dispensing of a prescription drug in
23 accordance with chapter 465.
24 Section 20. (1) The Agency for Health Care
25 Administration shall conduct a study of health care services
26 provided to the medically fragile or
27 medical-technology-dependent children in the state and conduct
28 a pilot program in Miami-Dade County to provide subacute
29 pediatric transitional care to a maximum of 30 children at any
30 one time. The purposes of the study and the pilot program are
31 to determine ways to permit medically fragile or
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1 medical-technology-dependent children to successfully make a
2 transition from acute care in a health care institution to
3 live with their families when possible, and to provide
4 cost-effective, subacute transitional care services.
5 (2) The Agency for Health Care Administration, in
6 cooperation with the Children's Medical Services Program in
7 the Department of Health, shall conduct a study to identify
8 the total number of medically fragile or
9 medical-technology-dependent children, from birth through age
10 21, in the state. By January 1, 2003, the agency must report
11 to the Legislature regarding the children's ages, the
12 locations where the children are served, the types of services
13 received, itemized costs of the services, and the sources of
14 funding that pay for the services, including the proportional
15 share when more than one funding source pays for a service.
16 The study must include information regarding medically fragile
17 or medical-technology-dependent children residing in
18 hospitals, nursing homes, and medical foster care, and those
19 who live with their parents. The study must describe children
20 served in prescribed pediatric extended-care centers,
21 including their ages and the services they receive. The report
22 must identify the total services provided for each child and
23 the method for paying for those services. The report must also
24 identify the number of such children who could, if appropriate
25 transitional services were available, return home or move to a
26 less-institutional setting.
27 (3) Within 30 days after the effective date of this
28 act, the agency shall establish minimum staffing standards and
29 quality requirements for a subacute pediatric transitional
30 care center to be operated as a 2-year pilot program in Dade
31 County. The pilot program must operate under the license of a
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 hospital licensed under chapter 395, Florida Statutes, or a
2 nursing home licensed under chapter 400, Florida Statutes, and
3 shall use existing beds in the hospital or nursing home. A
4 child's placement in the subacute pediatric transitional care
5 center may not exceed 90 days. The center shall arrange for an
6 alternative placement at the end of a child's stay and a
7 transitional plan for children expected to remain in the
8 facility for the maximum allowed stay.
9 (4) Within 60 days after the effective date of this
10 act, the agency must amend the state Medicaid plan and request
11 any federal waivers necessary to implement and fund the pilot
12 program.
13 (5) The subacute pediatric transitional care center
14 must require level I background screening as provided in
15 chapter 435, Florida Statutes, for all employees or
16 prospective employees of the center who are expected to, or
17 whose responsibilities may require them to, provide personal
18 care or services to children, have access to children's living
19 areas, or have access to children's funds or personal
20 property.
21 (6) The subacute pediatric transitional care center
22 must have an advisory board. Membership on the advisory board
23 must include, but need not be limited to:
24 (a) A physician and an advanced registered nurse
25 practitioner who is familiar with services for medically
26 fragile or medical-technology-dependent children;
27 (b) A registered nurse who has experience in the care
28 of medically fragile or medical-technology-dependent children;
29 (c) A child development specialist who has experience
30 in the care of medically fragile or
31 medical-technology-dependent children and their families;
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (d) A social worker who has experience in the care of
2 medically fragile or medical-technology-dependent children and
3 their families; and
4 (e) A consumer representative who is a parent or
5 guardian of a child placed in the center.
6 (7) The advisory board shall:
7 (a) Review the policy and procedure components of the
8 center to assure conformance with applicable standards
9 developed by the Agency for Health Care Administration; and
10 (b) Provide consultation with respect to the
11 operational and programmatic components of the center.
12 (8) The subacute pediatric transitional care center
13 must have written policies and procedures governing the
14 admission, transfer, and discharge of children.
15 (9) The admission of each child to the center must be
16 under the supervision of the center nursing administrator or
17 his or her designee, and must be in accordance with the
18 center's policies and procedures. Each Medicaid admission must
19 be approved as appropriate for placement in the facility by
20 the Children's Medical Services Multidisciplinary Assessment
21 Team of the Department of Health, in conjunction with the
22 Agency for Health Care Administration.
23 (10) Each child admitted to the center shall be
24 admitted upon prescription of the medical director of the
25 center, licensed pursuant to chapter 458 or chapter 459,
26 Florida Statutes, and the child shall remain under the care of
27 the medical director and the advanced registered nurse
28 practitioner for the duration of his or her stay in the
29 center.
30 (11) Each child admitted to the center must meet at
31 least the following criteria:
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 (a) The child must be medically fragile or
2 medical-technology-dependent.
3 (b) The child may not, prior to admission, present
4 significant risk of infection to other children or personnel.
5 The medical and nursing directors shall review, on a
6 case-by-case basis, the condition of any child who is
7 suspected of having an infectious disease to determine whether
8 admission is appropriate.
9 (c) The child must be medically stabilized and require
10 skilled nursing care or other interventions.
11 (12) If the child meets the criteria specified in
12 paragraphs (11)(a), (b), and (c), the medical director or
13 nursing director of the center shall implement a preadmission
14 plan that delineates services to be provided and appropriate
15 sources for such services.
16 (a) If the child is hospitalized at the time of
17 referral, preadmission planning must include the participation
18 of the child's parent or guardian and relevant medical,
19 nursing, social services, and developmental staff to assure
20 that the hospital's discharge plans will be implemented
21 following the child's placement in the center.
22 (b) A consent form, outlining the purpose of the
23 center, family responsibilities, authorized treatment,
24 appropriate release of liability, and emergency disposition
25 plans, must be signed by the parent or guardian and witnessed
26 before the child is admitted to the center. The parent or
27 guardian shall be provided a copy of the consent form.
28 (13) By January 1, 2003, the Agency for Health Care
29 Administration shall report to the Legislature concerning the
30 progress of the pilot program. By January 1, 2004, the agency
31 shall submit to the Legislature a report on the success of the
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 pilot program.
2 Section 21. The Office of Legislative Services shall
3 contract for a business case study of the feasibility of
4 outsourcing the administrative, investigative, legal, and
5 prosecutorial functions and other tasks and services that are
6 necessary to carry out the regulatory responsibilities of the
7 Board of Dentistry, employing its own executive director and
8 other staff, and obtaining authority over collections and
9 expenditures of funds paid by professions regulated by the
10 board into the Medical Quality Assurance Trust Fund. This
11 feasibility study must include a business plan and an
12 assessment of the direct and indirect costs associated with
13 outsourcing these functions. The sum of $50,000 is
14 appropriated from the Board of Dentistry account within the
15 Medical Quality Assurance Trust Fund to the Office of
16 Legislative Services for the purpose of contracting for the
17 study. The Office of Legislative Services shall submit the
18 completed study to the Governor, the President of the Senate,
19 and the Speaker of the House of Representatives by January 1,
20 2003.
21 Section 22. (1) Notwithstanding section 409.911(3),
22 Florida Statutes, for the state fiscal year 2002-2003 only,
23 the agency shall distribute moneys under the regular
24 disproportionate share program only to hospitals that meet the
25 federal minimum requirements and to public hospitals. Public
26 hospitals are defined as those hospitals identified as
27 government owned or operated in the Financial Hospital Uniform
28 Reporting System (FHURS) data available to the agency as of
29 January 1, 2002. The following methodology shall be used to
30 distribute disproportionate share dollars to hospitals that
31 meet the federal minimum requirements and to the public
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 hospitals:
2 (a) For hospitals that meet the federal minimum
3 requirements, the following formula shall be used:
4
5 TAA = TA * (1/5.5)
6 DSHP = (HMD/TMSD)*TA
7
8 TAA = total amount available.
9 TA = total appropriation.
10 DSHP = disproportionate share hospital payment.
11 HMD = hospital Medicaid days.
12 TSD = total state Medicaid days.
13
14 (b) The following formulas shall be used to pay
15 disproportionate share dollars to public hospitals:
16 1. For state mental health hospitals:
17
18 DSHP = (HMD/TMD) * TAAMH
19
20 The total amount available for the state mental
21 health hospitals shall be the difference
22 between the federal cap for Institutions for
23 Mental Diseases and the amounts paid under the
24 mental health disproportionate share program.
25 2. For non-state government owned or operated
26 hospitals with 3,200 or more Medicaid days:
27
28 DSHP = [(.85*HCCD/TCCD) + (.15*HMD/TMD)] *
29 TAAPH
30 TAAPH = TAA - TAAMH
31
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 3. For non-state government owned or operated
2 hospitals with less than 3,200 Medicaid days, a total of
3 $400,000 shall be distributed equally among these hospitals.
4
5 Where:
6
7 TAA = total available appropriation.
8 TAAPH = total amount available for public
9 hospitals.
10 TAAMH = total amount available for mental
11 health hospitals.
12 DSHP = disproportionate share hospital
13 payments.
14 HMD = hospital Medicaid days.
15 TMD = total state Medicaid days for public
16 hospitals.
17 HCCD = hospital charity care dollars.
18 TCCD = total state charity care dollars for
19 public hospitals.
20
21 In computing the above amounts for public hospitals and
22 hospitals that qualify under the federal minimum requirements,
23 the agency shall use the 1997 audited data. In the event there
24 is no 1997 audited data for a hospital, the agency shall use
25 the 1994 audited data.
26 (2) Notwithstanding section 409.9112, Florida
27 Statutes, for state fiscal year 2002-2003, only
28 disproportionate share payments to regional perinatal
29 intensive care centers shall be distributed in the same
30 proportion as the disproportionate share payments made to the
31 regional perinatal intensive care centers in the state fiscal
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 year 2001-2002.
2 (3) Notwithstanding section 409.9117, Florida
3 Statutes, for state fiscal year 2002-2003 only,
4 disproportionate share payments to hospitals that qualify for
5 primary care disproportionate share payments shall be
6 distributed in the same proportion as the primary care
7 disproportionate share payments made to those hospitals in the
8 state fiscal year 2001-2002.
9 (4) In the event the Centers for Medicare and Medicaid
10 Services does not approve Florida's inpatient hospital state
11 plan amendment for the public disproportionate share program
12 by November 1, 2002, the agency may make payments to hospitals
13 under the regular disproportionate share program, regional
14 perinatal intensive care centers disproportionate share
15 program, and the primary care disproportionate share program
16 using the same methodologies used in state fiscal year
17 2001-2002.
18 (5) For state fiscal year 2002-2003 only, no
19 disproportionate share payments shall be made to specialty
20 hospitals for children under the provisions of section
21 409.9119, Florida Statutes.
22 (6) This section expires July 1, 2003.
23 Section 23. The Agency for Health Care Administration
24 may conduct a 2-year pilot project to authorize overnight
25 stays in one ambulatory surgical center located in Acute Care
26 Subdistrict 9-1. An overnight stay shall be permitted only to
27 perform plastic and reconstructive surgeries defined by
28 current procedural terminology code numbers 13000-19999. The
29 total time a patient is at the ambulatory surgical center
30 shall not exceed 23 hours and 59 minutes, including the
31 surgery time, and the maximum planned duration of all surgical
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 procedures combined shall not exceed 8 hours. Prior to
2 implementation of the pilot project, the agency shall
3 establish minimum requirements for protecting the health,
4 safety, and welfare of patients receiving overnight care.
5 These shall include, at a minimum, compliance with all
6 statutes and rules applicable to ambulatory surgical centers
7 and the requirements set forth in Rule 64B8-9.009, F.A.C.,
8 relating to Level II and Level III procedures. If the agency
9 implements the pilot project, it shall, within 6 months after
10 its completion, submit a report to the Legislature on whether
11 to expand the pilot to include all ambulatory surgical
12 centers. The recommendation shall be based on consideration of
13 the efficacy and impact to patient safety and quality of
14 patient care of providing plastic and reconstructive surgeries
15 in the ambulatory surgical center setting. The agency is
16 authorized to obtain such data as necessary to implement this
17 section.
18 Section 24. Section 624.91, Florida Statutes, is
19 amended to read:
20 624.91 The Florida Healthy Kids Corporation Act.--
21 (1) SHORT TITLE.--This section may be cited as the
22 "William G. 'Doc' Myers Healthy Kids Corporation Act."
23 (2) LEGISLATIVE INTENT.--
24 (a) The Legislature finds that increased access to
25 health care services could improve children's health and
26 reduce the incidence and costs of childhood illness and
27 disabilities among children in this state. Many children do
28 not have comprehensive, affordable health care services
29 available. It is the intent of the Legislature that the
30 Florida Healthy Kids Corporation provide comprehensive health
31 insurance coverage to such children. The corporation is
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 encouraged to cooperate with any existing health service
2 programs funded by the public or the private sector and to
3 work cooperatively with the Florida Partnership for School
4 Readiness.
5 (b) It is the intent of the Legislature that the
6 Florida Healthy Kids Corporation serve as one of several
7 providers of services to children eligible for medical
8 assistance under Title XXI of the Social Security Act.
9 Although the corporation may serve other children, the
10 Legislature intends the primary recipients of services
11 provided through the corporation be school-age children with a
12 family income below 200 percent of the federal poverty level,
13 who do not qualify for Medicaid. It is also the intent of the
14 Legislature that state and local government Florida Healthy
15 Kids funds, to the extent permissible under federal law, be
16 used to continue and expand coverage, within available
17 appropriations, to children not eligible for federal matching
18 funds under Title XXI obtain matching federal dollars.
19 (3) NONENTITLEMENT.--Nothing in this section shall be
20 construed as providing an individual with an entitlement to
21 health care services. No cause of action shall arise against
22 the state, the Florida Healthy Kids Corporation, or a unit of
23 local government for failure to make health services available
24 under this section.
25 (4) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
26 (a) There is created the Florida Healthy Kids
27 Corporation, a not-for-profit corporation which operates on
28 sites designated by the corporation.
29 (b) The Florida Healthy Kids Corporation shall phase
30 in a program to:
31 1. Organize school children groups to facilitate the
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 provision of comprehensive health insurance coverage to
2 children;
3 2. Arrange for the collection of any family, local
4 contributions, or employer payment or premium, in an amount to
5 be determined by the board of directors, to provide for
6 payment of premiums for comprehensive insurance coverage and
7 for the actual or estimated administrative expenses;
8 3. Arrange for the collection of any voluntary
9 contributions to provide for payment of premiums for children
10 who are not eligible for medical assistance under Title XXI of
11 the Social Security Act. Each fiscal year, the corporation
12 shall establish a local-match policy for the enrollment of
13 non-Title XXI eligible children in the Healthy Kids program.
14 By May 1 of each year, the corporation shall provide written
15 notification of the amount to be remitted to the corporation
16 for the following fiscal year under that policy. Local-match
17 sources may include, but are not limited to, funds provided by
18 municipalities, counties, school boards, hospitals, health
19 care providers, charitable organizations, special taxing
20 districts, and private organizations. The minimum local-match
21 cash contributions required each fiscal year and local-match
22 credits shall be determined by the General Appropriations Act.
23 The corporation shall calculate a county's local-match rate
24 based upon that county's percentage of the state's total
25 non-Title XXI expenditures as reported in the corporation's
26 most recently audited financial statement. In awarding the
27 local-match credits, the corporation may consider factors
28 including, but not limited to, population density, per-capita
29 income, existing child-health-related expenditures and
30 services in awarding the credits.
31 4. Accept voluntary supplemental local-match
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 contributions that comply with the requirements of Title XXI
2 of the Social Security Act for the purpose of providing
3 additional coverage in contributing counties under Title XXI.
4 5.3. Establish the administrative and accounting
5 procedures for the operation of the corporation;
6 6.4. Establish, with consultation from appropriate
7 professional organizations, standards for preventive health
8 services and providers and comprehensive insurance benefits
9 appropriate to children; provided that such standards for
10 rural areas shall not limit primary care providers to
11 board-certified pediatricians;
12 7.5. Establish eligibility criteria which children
13 must meet in order to participate in the program;
14 8.6. Establish procedures under which providers of
15 local match to, applicants to and participants in the program
16 may have grievances reviewed by an impartial body and reported
17 to the board of directors of the corporation;
18 9.7. Establish participation criteria and, if
19 appropriate, contract with an authorized insurer, health
20 maintenance organization, or insurance administrator to
21 provide administrative services to the corporation;
22 10.8. Establish enrollment criteria which shall
23 include penalties or waiting periods of not fewer than 60 days
24 for reinstatement of coverage upon voluntary cancellation for
25 nonpayment of family premiums;
26 11.9. If a space is available, establish a special
27 open enrollment period of 30 days' duration for any child who
28 is enrolled in Medicaid or Medikids if such child loses
29 Medicaid or Medikids eligibility and becomes eligible for the
30 Florida Healthy Kids program;
31 12.10. Contract with authorized insurers or any
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 provider of health care services, meeting standards
2 established by the corporation, for the provision of
3 comprehensive insurance coverage to participants. Such
4 standards shall include criteria under which the corporation
5 may contract with more than one provider of health care
6 services in program sites. Health plans shall be selected
7 through a competitive bid process. The selection of health
8 plans shall be based primarily on quality criteria established
9 by the board. The health plan selection criteria and scoring
10 system, and the scoring results, shall be available upon
11 request for inspection after the bids have been awarded;
12 13. Establish disenrollment criteria in the event
13 local matching funds are insufficient to cover enrollments.
14 14.11. Develop and implement a plan to publicize the
15 Florida Healthy Kids Corporation, the eligibility requirements
16 of the program, and the procedures for enrollment in the
17 program and to maintain public awareness of the corporation
18 and the program;
19 15.12. Secure staff necessary to properly administer
20 the corporation. Staff costs shall be funded from state and
21 local matching funds and such other private or public funds as
22 become available. The board of directors shall determine the
23 number of staff members necessary to administer the
24 corporation;
25 16.13. As appropriate, enter into contracts with local
26 school boards or other agencies to provide onsite information,
27 enrollment, and other services necessary to the operation of
28 the corporation;
29 17.14. Provide a report on an annual basis to the
30 Governor, Insurance Commissioner, Commissioner of Education,
31 Senate President, Speaker of the House of Representatives, and
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 Minority Leaders of the Senate and the House of
2 Representatives;
3 18.15. Each fiscal year, establish a maximum number of
4 participants by county, on a statewide basis, who may enroll
5 in the program; and without the benefit of local matching
6 funds. Thereafter, the corporation may establish local
7 matching requirements for supplemental participation in the
8 program. The corporation may vary local matching requirements
9 and enrollment by county depending on factors which may
10 influence the generation of local match, including, but not
11 limited to, population density, per capita income, existing
12 local tax effort, and other factors. The corporation also may
13 accept in-kind match in lieu of cash for the local match
14 requirement to the extent allowed by Title XXI of the Social
15 Security Act; and
16 19.16. Establish eligibility criteria, premium and
17 cost-sharing requirements, and benefit packages which conform
18 to the provisions of the Florida Kidcare program, as created
19 in ss. 409.810-409.820.
20 (c) Coverage under the corporation's program is
21 secondary to any other available private coverage held by the
22 participant child or family member. The corporation may
23 establish procedures for coordinating benefits under this
24 program with benefits under other public and private coverage.
25 (d) The Florida Healthy Kids Corporation shall be a
26 private corporation not for profit, organized pursuant to
27 chapter 617, and shall have all powers necessary to carry out
28 the purposes of this act, including, but not limited to, the
29 power to receive and accept grants, loans, or advances of
30 funds from any public or private agency and to receive and
31 accept from any source contributions of money, property,
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 labor, or any other thing of value, to be held, used, and
2 applied for the purposes of this act.
3 (5) BOARD OF DIRECTORS.--
4 (a) The Florida Healthy Kids Corporation shall operate
5 subject to the supervision and approval of a board of
6 directors chaired by the Insurance Commissioner or her or his
7 designee, and composed of 14 12 other members selected for
8 3-year terms of office as follows:
9 1. One member appointed by the Commissioner of
10 Education from among three persons nominated by the Florida
11 Association of School Administrators;
12 2. One member appointed by the Commissioner of
13 Education from among three persons nominated by the Florida
14 Association of School Boards;
15 3. One member appointed by the Commissioner of
16 Education from the Office of School Health Programs of the
17 Florida Department of Education;
18 4. One member appointed by the Governor from among
19 three members nominated by the Florida Pediatric Society;
20 5. One member, appointed by the Governor, who
21 represents the Children's Medical Services Program;
22 6. One member appointed by the Insurance Commissioner
23 from among three members nominated by the Florida Hospital
24 Association;
25 7. Two members, appointed by the Insurance
26 Commissioner, who are representatives of authorized health
27 care insurers or health maintenance organizations;
28 8. One member, appointed by the Insurance
29 Commissioner, who represents the Institute for Child Health
30 Policy;
31 9. One member, appointed by the Governor, from among
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 three members nominated by the Florida Academy of Family
2 Physicians;
3 10. One member, appointed by the Governor, who
4 represents the Agency for Health Care Administration; and
5 11. The State Health Officer or her or his designee;.
6 12. One member, appointed by the Insurance
7 Commissioner from among three members nominated by the Florida
8 Association of Counties, representing rural counties; and
9 13. One member, appointed by the Governor from among
10 three members nominated by the Florida Association of
11 Counties, representing urban counties.
12 (b) A member of the board of directors may be removed
13 by the official who appointed that member. The board shall
14 appoint an executive director, who is responsible for other
15 staff authorized by the board.
16 (c) Board members are entitled to receive, from funds
17 of the corporation, reimbursement for per diem and travel
18 expenses as provided by s. 112.061.
19 (d) There shall be no liability on the part of, and no
20 cause of action shall arise against, any member of the board
21 of directors, or its employees or agents, for any action they
22 take in the performance of their powers and duties under this
23 act.
24 (6) LICENSING NOT REQUIRED; FISCAL OPERATION.--
25 (a) The corporation shall not be deemed an insurer.
26 The officers, directors, and employees of the corporation
27 shall not be deemed to be agents of an insurer. Neither the
28 corporation nor any officer, director, or employee of the
29 corporation is subject to the licensing requirements of the
30 insurance code or the rules of the Department of Insurance.
31 However, any marketing representative utilized and compensated
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 by the corporation must be appointed as a representative of
2 the insurers or health services providers with which the
3 corporation contracts.
4 (b) The board has complete fiscal control over the
5 corporation and is responsible for all corporate operations.
6 (c) The Department of Insurance shall supervise any
7 liquidation or dissolution of the corporation and shall have,
8 with respect to such liquidation or dissolution, all power
9 granted to it pursuant to the insurance code.
10 (7) ACCESS TO RECORDS; CONFIDENTIALITY;
11 PENALTIES.--Notwithstanding any other laws to the contrary,
12 the Florida Healthy Kids Corporation shall have access to the
13 medical records of a student upon receipt of permission from a
14 parent or guardian of the student. Such medical records may
15 be maintained by state and local agencies. Any identifying
16 information, including medical records and family financial
17 information, obtained by the corporation pursuant to this
18 subsection is confidential and is exempt from the provisions
19 of s. 119.07(1). Neither the corporation nor the staff or
20 agents of the corporation may release, without the written
21 consent of the participant or the parent or guardian of the
22 participant, to any state or federal agency, to any private
23 business or person, or to any other entity, any confidential
24 information received pursuant to this subsection. A violation
25 of this subsection is a misdemeanor of the second degree,
26 punishable as provided in s. 775.082 or s. 775.083.
27 Section 25. Subsection (5) of section 414.41, Florida
28 Statutes, is repealed.
29 Section 26. If any law that is amended by this act was
30 also amended by a law enacted at the 2002 Regular Session of
31 the Legislature, such laws shall be construed as if they had
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 been enacted at the same session of the Legislature, and full
2 effect should be given to each if that is possible.
3 Section 27. Except as otherwise provided in this act,
4 this act shall take effect upon becoming a law.
5
6
7 ================ T I T L E A M E N D M E N T ===============
8 And the title is amended as follows:
9 Delete everything before the enacting clause
10
11 and insert:
12 A bill to be entitled
13 An act relating to health care; amending s.
14 16.59, F.S.; specifying additional requirements
15 for the Medicaid Fraud Control Unit of the
16 Department of Legal Affairs and the Medicaid
17 program integrity program; amending s.
18 112.3187, F.S.; extending whistle-blower
19 protection to employees of Medicaid providers
20 reporting Medicaid fraud or abuse; amending s.
21 400.179, F.S.; providing exceptions to bond
22 requirements; creating s. 408.831, F.S.;
23 allowing the Agency for Health Care
24 Administration to take action against a
25 licensee in certain circumstances; amending s.
26 409.8177, F.S.; requiring the Agency for Health
27 Care Administration to contract for an
28 evaluation of the Florida Kidcare program;
29 amending s. 409.902, F.S.; prescribing an
30 additional condition on Medicaid eligibility;
31 amending s. 409.904, F.S.; revising provisions
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 governing optional payments for medical
2 assistance and related services; amending s.
3 409.905, F.S.; providing additional criteria
4 for the agency to adjust a hospital's inpatient
5 per diem rate for Medicaid; amending s.
6 409.906, F.S.; authorizing the agency to make
7 payments for specified services which are
8 optional under Title XIX of the Social Security
9 Act; amending s. 409.9065, F.S.; revising
10 standards for pharmaceutical expense
11 assistance; amending s. 409.907, F.S.;
12 prescribing additional requirements with
13 respect to provider enrollment; requiring that
14 the Agency for Health Care Administration deny
15 a provider's application under certain
16 circumstances; amending s. 409.908, F.S.;
17 providing additional requirements for
18 cost-reporting; amending s. 409.910, F.S.;
19 revising requirements for the distribution of
20 funds recovered from third parties that are
21 liable for making payments for medical care
22 furnished to Medicaid recipients and in the
23 case of recoveries of overpayments; amending s.
24 409.912, F.S.; revising provisions governing
25 the purchase of goods and services for Medicaid
26 recipients; providing for quarterly reports to
27 the Governor and presiding officers of the
28 Legislature; amending s. 409.9116, F.S.;
29 revising the disproportionate share/financial
30 assistance program for rural hospitals;
31 amending s. 409.9122, F.S.; revising provisions
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Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 governing mandatory Medicaid managed care
2 enrollment; amending s. 409.913, F.S.;
3 requiring that the agency and Medicaid Fraud
4 Control Unit annually submit a report to the
5 Legislature; defining the term "complaint";
6 specifying additional requirements for the
7 Medicaid program integrity program and the
8 Medicaid Fraud Control Unit of the Department
9 of Legal Affairs; requiring imposition of
10 sanctions or disincentives, except under
11 certain circumstances; providing additional
12 sanctions and disincentives; providing
13 additional grounds under which the agency may
14 terminate a provider's participation in the
15 Medicaid program; providing additional
16 requirements for administrative hearings;
17 providing additional grounds for withholding
18 payments to a provider; authorizing the agency
19 and the Medicaid Fraud Control Unit to review
20 certain records; requiring review by the
21 Attorney General of certain settlements;
22 requiring review by the Auditor General of
23 certain cost reports; requiring that the agency
24 refund to a county any recovery of Medicaid
25 overpayment received for hospital inpatient and
26 nursing home services; providing a formula for
27 calculating the credit; amending s. 409.920,
28 F.S.; providing additional duties of the
29 Medicaid Fraud Control Unit; amending s.
30 499.012, F.S.; redefining the term "wholesale
31 distribution" with respect to regulation of
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 distribution of prescription drugs; requiring
2 the Agency for Health Care Administration to
3 conduct a study of health care services
4 provided to medically fragile or
5 medical-technology-dependent children;
6 requiring the Agency for Health Care
7 Administration to conduct a pilot program for a
8 subacute pediatric transitional care center;
9 requiring background screening of center
10 personnel; requiring the agency to amend the
11 Medicaid state plan and seek federal waivers as
12 necessary; requiring the center to have an
13 advisory board; providing for membership on the
14 advisory board; providing requirements for the
15 admission, transfer, and discharge of a child
16 to the center; requiring the agency to submit
17 certain reports to the Legislature; providing
18 guidelines for the agency to distribute
19 disproportionate share funds during the
20 2002-2003 fiscal year; authorizing the Agency
21 for Health Care Administration to conduct a
22 pilot project on overnight stays in an
23 ambulatory surgical center; amending s. 624.91,
24 F.S.; revising duties of the Florida Healthy
25 Kids Corporation with respect to annual
26 determination of participation in the Healthy
27 Kids Program; prescribing duties of the
28 corporation in establishing local match
29 requirements; revising the composition of the
30 board of directors; requiring recommendations
31 to the Legislature; repealing s. 414.41(5),
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SENATE AMENDMENT
Bill No. HB 59-E, 1st Eng.
Amendment No. ___ Barcode 934922
1 F.S., relating to interest imposed upon the
2 recovery amount of medical assistance
3 overpayments; providing for construction of
4 laws enacted at the 2002 Regular Session in
5 relation to this act; providing effective
6 dates.
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