House Bill hb0059E
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Florida House of Representatives - 2002 HB 59-E
By the Fiscal Responsibility Council and Representative
Murman
1 A bill to be entitled
2 An act relating to health care; amending s.
3 112.3187, F.S.; revising procedures and
4 requirements relating to whistle-blower
5 protection for reporting Medicaid fraud or
6 abuse; amending s. 400.179, F.S.; providing an
7 alternative to certain bond requirements for
8 protection against nursing home Medicaid
9 overpayments; providing for review and
10 rulemaking authority of the Agency for Health
11 Care Administration; providing for future
12 repeal; requiring a report; creating s.
13 408.831, F.S.; authorizing the Agency for
14 Health Care Administration to take action
15 against a regulated entity under certain
16 circumstances; reenacting s. 409.8132(4), F.S.,
17 to incorporate amendments to ss. 409.902,
18 409.907, 409.908, and 409.913, F.S., in
19 references thereto; amending s. 409.8177, F.S.;
20 requiring the agency to contract for evaluation
21 of the Florida Kidcare program; amending s.
22 409.902, F.S.; requiring consent for release of
23 medical records to the agency and the Medicaid
24 Fraud Control Unit as a condition of Medicaid
25 eligibility; amending s. 409.903, F.S.;
26 revising eligibility for certain Medicaid
27 mandatory medical assistance; amending s.
28 409.904, F.S.; revising eligibility standards
29 for certain Medicaid optional medical
30 assistance; amending s. 409.9065, F.S.;
31 revising eligibility standards for the
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1 pharmaceutical expense assistance program;
2 amending s. 409.907, F.S.; prescribing
3 additional requirements with respect to
4 Medicaid provider enrollment; requiring the
5 agency to deny a provider's application under
6 certain circumstances; amending s. 409.908,
7 F.S.; requiring retroactive calculation of cost
8 report if requirements for cost reporting are
9 not met; revising provisions relating to rate
10 adjustments to offset the cost of general and
11 professional liability insurance for nursing
12 homes; extending authorization for special
13 Medicaid payments to qualified providers;
14 providing for intergovernmental transfer of
15 payments; amending s. 409.911, F.S.; expanding
16 application of definitions; amending s.
17 409.9116, F.S.; revising applicability of the
18 disproportionate share/financial assistance
19 program for rural hospitals; amending s.
20 409.91195, F.S.; granting interested parties
21 opportunity to present public testimony before
22 the Medicaid Pharmaceutical and Therapeutics
23 Committee; amending s. 409.912, F.S.; providing
24 requirements for contracts for Medicaid
25 behavioral health care services; amending s.
26 409.9122, F.S.; revising procedures relating to
27 assignment of a Medicaid recipient to a managed
28 care plan or MediPass provider; granting agency
29 discretion to renew contracts; amending s.
30 409.913, F.S.; requiring the agency and the
31 Medicaid Fraud Control Unit to annually submit
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1 a joint report to the Legislature; defining the
2 term "complaint" with respect to Medicaid fraud
3 or abuse; specifying additional requirements
4 for the Medicaid program integrity program and
5 the Medicaid Fraud Control Unit; providing
6 additional sanctions and disincentives which
7 may be imposed; providing additional grounds
8 for termination of a provider's participation
9 in the Medicaid program; providing additional
10 requirements for administrative hearings;
11 providing additional grounds for withholding
12 payments to a provider; authorizing the agency
13 and the Medicaid Fraud Control Unit to review
14 certain records; amending s. 409.920, F.S.;
15 providing additional duties of the Attorney
16 General with respect to Medicaid fraud control;
17 amending s. 624.91, F.S.; revising duties of
18 the Florida Healthy Kids Corporation with
19 respect to annual determination of
20 participation in the Healthy Kids program;
21 prescribing duties of the corporation in
22 establishing local match requirements; revising
23 composition of the board of directors; amending
24 s. 383.19, F.S.; revising limitation on the
25 establishment of regional perinatal intensive
26 care centers; amending s. 393.063, F.S.;
27 revising definition of the term "intermediate
28 care facility for the developmentally disabled"
29 for purposes of ch. 393, F.S.; amending ss.
30 400.965 and 400.968, F.S.; providing penalties
31 for violation of pt. XI of ch. 400, F.S.,
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1 relating to intermediate care facilities for
2 developmentally disabled persons; requiring the
3 Department of Children and Family Services to
4 develop and implement a comprehensive redesign
5 of the home and community-based services
6 delivery system for persons with developmental
7 disabilities; restricting certain release of
8 funds; providing an implementation schedule;
9 requiring the Agency for Health Care
10 Administration to conduct a study of health
11 care services provided to children who are
12 medically fragile or dependent on medical
13 technology; requiring the agency to conduct a
14 pilot program for a subacute pediatric
15 transitional care center; requiring background
16 screening of center personnel; requiring the
17 agency to amend the Medicaid state plan or seek
18 federal waivers as necessary; requiring the
19 center to have an advisory board; providing for
20 membership and duties of the advisory board;
21 providing requirements for the admission,
22 transfer, and discharge of a child to the
23 center; requiring the agency to submit certain
24 reports to the Legislature; requiring the
25 agency to make recommendations to the
26 Legislature regarding limitations on certain
27 Medicaid provider reimbursements; providing
28 guidelines for the agency regarding
29 distribution of disproportionate share funds
30 during the 2002-2003 fiscal year; directing the
31 Office of Program Policy Analysis and
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1 Government Accountability to perform a study of
2 county contributions to Medicaid nursing home
3 costs; requiring a report and recommendations;
4 repealing s. 1, ch. 2001-377, Laws of Florida,
5 relating to eligibility of specified persons
6 for certain optional medical assistance;
7 providing severability; providing effective
8 dates.
9
10 Be It Enacted by the Legislature of the State of Florida:
11
12 Section 1. Subsections (3), (5), and (7) of section
13 112.3187, Florida Statutes, are amended to read:
14 112.3187 Adverse action against employee for
15 disclosing information of specified nature prohibited;
16 employee remedy and relief.--
17 (3) DEFINITIONS.--As used in this act, unless
18 otherwise specified, the following words or terms shall have
19 the meanings indicated:
20 (a) "Agency" means any state, regional, county, local,
21 or municipal government entity, whether executive, judicial,
22 or legislative; any official, officer, department, division,
23 bureau, commission, authority, or political subdivision
24 therein; or any public school, community college, or state
25 university.
26 (b) "Employee" means a person who performs services
27 for, and under the control and direction of, or contracts
28 with, an agency or independent contractor for wages or other
29 remuneration.
30 (c) "Adverse personnel action" means the discharge,
31 suspension, transfer, or demotion of any employee or the
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1 withholding of bonuses, the reduction in salary or benefits,
2 or any other adverse action taken against an employee within
3 the terms and conditions of employment by an agency or
4 independent contractor.
5 (d) "Independent contractor" means a person, other
6 than an agency, engaged in any business and who enters into a
7 contract, including a provider agreement, with an agency.
8 (e) "Gross mismanagement" means a continuous pattern
9 of managerial abuses, wrongful or arbitrary and capricious
10 actions, or fraudulent or criminal conduct which may have a
11 substantial adverse economic impact.
12 (5) NATURE OF INFORMATION DISCLOSED.--The information
13 disclosed under this section must include:
14 (a) Any violation or suspected violation of any
15 federal, state, or local law, rule, or regulation committed by
16 an employee or agent of an agency or independent contractor
17 which creates and presents a substantial and specific danger
18 to the public's health, safety, or welfare.
19 (b) Any act or suspected act of gross mismanagement,
20 malfeasance, misfeasance, gross waste of public funds,
21 suspected or actual Medicaid fraud or abuse, or gross neglect
22 of duty committed by an employee or agent of an agency or
23 independent contractor.
24 (7) EMPLOYEES AND PERSONS PROTECTED.--This section
25 protects employees and persons who disclose information on
26 their own initiative in a written and signed complaint; who
27 are requested to participate in an investigation, hearing, or
28 other inquiry conducted by any agency or federal government
29 entity; who refuse to participate in any adverse action
30 prohibited by this section; or who initiate a complaint
31 through the whistle-blower's hotline or the hotline of the
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1 Medicaid Fraud Control Unit of the Department of Legal
2 Affairs; or employees who file any written complaint to their
3 supervisory officials or employees who submit a complaint to
4 the Chief Inspector General in the Executive Office of the
5 Governor, to the employee designated as agency inspector
6 general under s. 112.3189(1), or to the Florida Commission on
7 Human Relations. The provisions of this section may not be
8 used by a person while he or she is under the care, custody,
9 or control of the state correctional system or, after release
10 from the care, custody, or control of the state correctional
11 system, with respect to circumstances that occurred during any
12 period of incarceration. No remedy or other protection under
13 ss. 112.3187-112.31895 applies to any person who has committed
14 or intentionally participated in committing the violation or
15 suspected violation for which protection under ss.
16 112.3187-112.31895 is being sought.
17 Section 2. Effective upon becoming a law and
18 applicable to any pending license renewal, paragraph (d) of
19 subsection (5) of section 400.179, Florida Statutes, is
20 amended to read:
21 400.179 Sale or transfer of ownership of a nursing
22 facility; liability for Medicaid underpayments and
23 overpayments.--
24 (5) Because any transfer of a nursing facility may
25 expose the fact that Medicaid may have underpaid or overpaid
26 the transferor, and because in most instances, any such
27 underpayment or overpayment can only be determined following a
28 formal field audit, the liabilities for any such underpayments
29 or overpayments shall be as follows:
30 (d) Where the transfer involves a facility that has
31 been leased by the transferor:
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1 1. The transferee shall, as a condition to being
2 issued a license by the agency, acquire, maintain, and provide
3 proof to the agency of a bond with a term of 30 months,
4 renewable annually, in an amount not less than the total of 3
5 months Medicaid payments to the facility computed on the basis
6 of the preceding 12-month average Medicaid payments to the
7 facility.
8 2. Subject to federal review and approval, a leasehold
9 licensee may meet the requirements of subparagraph 1. by
10 payment of a nonrefundable fee paid at initial licensure, paid
11 at the time of any subsequent change of ownership, and paid at
12 the time of any subsequent annual license renewal, in the
13 amount of 2 percent of the total of 3 months' Medicaid
14 payments to the facility computed on the basis of the
15 preceding 12-month average Medicaid payments to the facility.
16 If a preceding 12-month average is not available, projected
17 Medicaid payments may be used. The fee shall be deposited into
18 the Health Care Trust Fund and shall be accounted for
19 separately as a Medicaid nursing home overpayment account.
20 These fees shall be used at the sole discretion of the agency
21 to repay nursing home Medicaid overpayments. Payment of this
22 fee shall not release the operator from any liability for any
23 Medicaid overpayments nor shall payment bar the agency from
24 seeking to recoup overpayments from the operator and any other
25 liable party. As a condition of exercising this lease bond
26 alternative, licensees paying this fee must maintain the
27 remaining portion of an existing 30-month lease bond. The
28 agency is granted specific authority to promulgate all rules
29 pertaining to the administration and management of this
30 account, including withdrawals from the account. This
31 subparagraph is repealed on June 30, 2003.
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1 a. The financial viability of the Medicaid nursing
2 home overpayment account shall be determined by the agency
3 through annual review of the account balance and the amount of
4 total outstanding, unpaid Medicaid overpayments owing from
5 leasehold licensees to the agency as determined by final
6 agency audits.
7 (I) If the amount of the Medicaid nursing home
8 overpayment account at any time becomes less than the total
9 amount of such outstanding overpayments, then participation in
10 the account shall cease to be an acceptable alternative
11 assurance under this section and leasehold licensees shall be
12 required to immediately obtain lease bonds.
13 (II) Upon determining a deficit in the balance of the
14 account relative to such outstanding overpayments, the agency
15 shall determine the amount to be contributed by each
16 participating provider necessary to increase the account
17 balance to an amount in excess of the total outstanding amount
18 of such overpayments. The agency shall notify each licensee
19 participating in the account at the time a deficit was
20 determined of the amount each licensee must contribute to
21 eliminate the deficit. Upon elimination of the deficit in the
22 account, participation in the account shall be an acceptable
23 alternative assurance under this section.
24 b. The agency, in consultation with the Florida Health
25 Care Association and the Florida Association of Homes for the
26 Aging, shall study and make recommendations on the minimum
27 amount to be held in reserve to protect against Medicaid
28 overpayments to leasehold operators and on the issue of
29 successor liability for Medicaid overpayments upon sale or
30 transfer of ownership of a nursing facility. The agency shall
31 submit the findings and recommendations of the study to the
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1 Governor, the President of the Senate, and the Speaker of the
2 House of Representatives by January 1, 2003.
3 3.2. The leasehold operator may meet the bond
4 requirement through other arrangements acceptable to the
5 agency department.
6 4.3. All existing nursing facility licensees,
7 operating the facility as a leasehold, shall acquire,
8 maintain, and provide proof to the agency of the 30-month bond
9 required in subparagraph 1., above, on and after July 1, 1993,
10 for each license renewal.
11 5.4. It shall be the responsibility of all nursing
12 facility operators, operating the facility as a leasehold, to
13 renew the 30-month bond and to provide proof of such renewal
14 to the agency annually at the time of application for license
15 renewal.
16 6.5. Any failure of the nursing facility operator to
17 acquire, maintain, renew annually, or provide proof to the
18 agency shall be grounds for the agency to deny, cancel,
19 revoke, or suspend the facility license to operate such
20 facility and to take any further action, including, but not
21 limited to, enjoining the facility, asserting a moratorium, or
22 applying for a receiver, deemed necessary to ensure compliance
23 with this section and to safeguard and protect the health,
24 safety, and welfare of the facility's residents.
25 Section 3. Section 408.831, Florida Statutes, is
26 created to read:
27 408.831 Denial of application; suspension or
28 revocation of license, registration, or certificate.--
29 (1) In addition to any other remedies provided by law,
30 the agency may deny each application or suspend or revoke each
31
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1 license, registration, or certificate of entities regulated or
2 licensed by it:
3 (a) If the applicant, licensee, registrant, or
4 certificateholder, or, in the case of a corporation,
5 partnership, or other business entity, if any officer,
6 director, agent, or managing employee of that business entity
7 or any affiliated person, partner, or shareholder having an
8 ownership interest equal to 5 percent or greater in that
9 business entity, has failed to pay all outstanding fines,
10 liens, or overpayments assessed by final order of the agency
11 or final order of the Centers for Medicare and Medicaid
12 Services unless a repayment plan is approved by the agency; or
13 (b) For failure to comply with any repayment plan.
14 (2) For all legal proceedings that may result from a
15 denial, suspension, or revocation under this section,
16 testimony or documentation from the financial entity charged
17 with monitoring such payment shall constitute evidence of the
18 failure to pay an outstanding fine, lien, or overpayment and
19 shall be sufficient grounds for the denial, suspension, or
20 revocation.
21 (3) This section provides standards of enforcement
22 applicable to all entities licensed or regulated by the Agency
23 for Health Care Administration. This section controls over any
24 conflicting provisions of chapters 39, 381, 383, 390, 391,
25 393, 394, 395, 400, 408, 468, 483, and 641 or rules adopted
26 pursuant to those chapters.
27 Section 4. For the purpose of incorporating the
28 amendments made by this act to sections 409.902, 409.907,
29 409.908, and 409.913, Florida Statutes, in references thereto,
30 subsection (4) of section 409.8132, Florida Statutes, is
31 reenacted to read:
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1 409.8132 Medikids program component.--
2 (4) APPLICABILITY OF LAWS RELATING TO MEDICAID.--The
3 provisions of ss. 409.902, 409.905, 409.906, 409.907, 409.908,
4 409.912, 409.9121, 409.9122, 409.9123, 409.9124, 409.9127,
5 409.9128, 409.913, 409.916, 409.919, 409.920, and 409.9205
6 apply to the administration of the Medikids program component
7 of the Florida Kidcare program, except that s. 409.9122
8 applies to Medikids as modified by the provisions of
9 subsection (7).
10 Section 5. Section 409.8177, Florida Statutes, is
11 amended to read:
12 409.8177 Program evaluation.--
13 (1) The agency, in consultation with the Department of
14 Health, the Department of Children and Family Services, and
15 the Florida Healthy Kids Corporation, shall contract for an
16 evaluation of the Florida Kidcare program and shall by January
17 1 of each year submit to the Governor, the President of the
18 Senate, and the Speaker of the House of Representatives a
19 report of the Florida Kidcare program. In addition to the
20 items specified under s. 2108 of Title XXI of the Social
21 Security Act, the report shall include an assessment of
22 crowd-out and access to health care, as well as the following:
23 (a)(1) An assessment of the operation of the program,
24 including the progress made in reducing the number of
25 uncovered low-income children.
26 (b)(2) An assessment of the effectiveness in
27 increasing the number of children with creditable health
28 coverage, including an assessment of the impact of outreach.
29 (c)(3) The characteristics of the children and
30 families assisted under the program, including ages of the
31 children, family income, and access to or coverage by other
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1 health insurance prior to the program and after disenrollment
2 from the program.
3 (d)(4) The quality of health coverage provided,
4 including the types of benefits provided.
5 (e)(5) The amount and level, including payment of part
6 or all of any premium, of assistance provided.
7 (f)(6) The average length of coverage of a child under
8 the program.
9 (g)(7) The program's choice of health benefits
10 coverage and other methods used for providing child health
11 assistance.
12 (h)(8) The sources of nonfederal funding used in the
13 program.
14 (i)(9) An assessment of the effectiveness of Medikids,
15 Children's Medical Services network, and other public and
16 private programs in the state in increasing the availability
17 of affordable quality health insurance and health care for
18 children.
19 (j)(10) A review and assessment of state activities to
20 coordinate the program with other public and private programs.
21 (k)(11) An analysis of changes and trends in the state
22 that affect the provision of health insurance and health care
23 to children.
24 (l)(12) A description of any plans the state has for
25 improving the availability of health insurance and health care
26 for children.
27 (m)(13) Recommendations for improving the program.
28 (n)(14) Other studies as necessary.
29 (2) The agency shall also submit each month to the
30 Governor, the President of the Senate, and the Speaker of the
31
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1 House of Representatives a report of enrollment for each
2 program component of the Florida Kidcare program.
3 Section 6. Section 409.902, Florida Statutes, is
4 amended to read:
5 409.902 Designated single state agency; payment
6 requirements; program title; release of medical records.--The
7 Agency for Health Care Administration is designated as the
8 single state agency authorized to make payments for medical
9 assistance and related services under Title XIX of the Social
10 Security Act. These payments shall be made, subject to any
11 limitations or directions provided for in the General
12 Appropriations Act, only for services included in the program,
13 shall be made only on behalf of eligible individuals, and
14 shall be made only to qualified providers in accordance with
15 federal requirements for Title XIX of the Social Security Act
16 and the provisions of state law. This program of medical
17 assistance is designated the "Medicaid program." The
18 Department of Children and Family Services is responsible for
19 Medicaid eligibility determinations, including, but not
20 limited to, policy, rules, and the agreement with the Social
21 Security Administration for Medicaid eligibility
22 determinations for Supplemental Security Income recipients, as
23 well as the actual determination of eligibility. As a
24 condition of Medicaid eligibility, subject to federal
25 approval, the Agency for Health Care Administration and the
26 Department of Children and Family Services shall ensure that
27 each recipient of Medicaid consents to the release of her or
28 his medical records to the Agency for Health Care
29 Administration and the Medicaid Fraud Control Unit of the
30 Department of Legal Affairs.
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1 Section 7. Effective January 1, 2003, subsection (2)
2 of section 409.904, Florida Statutes, as amended by section 2
3 of chapter 2001-377, Laws of Florida, is amended to read:
4 409.904 Optional payments for eligible persons.--The
5 agency may make payments for medical assistance and related
6 services on behalf of the following persons who are determined
7 to be eligible subject to the income, assets, and categorical
8 eligibility tests set forth in federal and state law. Payment
9 on behalf of these Medicaid eligible persons is subject to the
10 availability of moneys and any limitations established by the
11 General Appropriations Act or chapter 216.
12 (2)(a) A caretaker relative or parent, a pregnant
13 woman, a child under age 19 who would otherwise qualify for
14 Medicaid or the Florida Kidcare program, a child up to age 21
15 who would otherwise qualify under s. 409.903(1), a person age
16 65 or over, or a blind or disabled person, who would otherwise
17 be eligible for Medicaid except that the income or assets of
18 such family or person exceed established limitations. A
19 pregnant woman who would otherwise qualify for Medicaid under
20 s. 409.903(5) except for her level of income and whose assets
21 fall within the limits established by the Department of
22 Children and Family Services for the medically needy. A
23 pregnant woman who applies for medically needy eligibility may
24 not be made presumptively eligible.
25 (b) A child under age 21 who would otherwise qualify
26 for Medicaid or the Florida Kidcare program except for the
27 family's level of income and whose assets fall within the
28 limits established by the Department of Children and Family
29 Services for the medically needy. For a family or person in
30 one of these coverage groups this group, medical expenses are
31 deductible from income in accordance with federal requirements
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1 in order to make a determination of eligibility. Expenses
2 used to meet spend-down liability are not reimbursable by
3 Medicaid. Effective January 1, 2003, when determining the
4 eligibility of a pregnant woman, a child, or an aged, blind,
5 or disabled individual, $360 shall be deducted from the
6 countable income of the filing unit. When determining the
7 eligibility of the caretaker relative or parent, as defined by
8 Title XIX of the Social Security Act, the additional income
9 disregard of $360 does not apply. A family or person who is
10 eligible under this coverage, in this group, which group is
11 known as the "medically needy," is eligible to receive the
12 same services as other Medicaid recipients, with the exception
13 of services in skilled nursing facilities and intermediate
14 care facilities for the developmentally disabled.
15 Section 8. Subsection (5) of section 409.903, Florida
16 Statutes, is amended to read:
17 409.903 Mandatory payments for eligible persons.--The
18 agency shall make payments for medical assistance and related
19 services on behalf of the following persons who the
20 department, or the Social Security Administration by contract
21 with the Department of Children and Family Services,
22 determines to be eligible, subject to the income, assets, and
23 categorical eligibility tests set forth in federal and state
24 law. Payment on behalf of these Medicaid eligible persons is
25 subject to the availability of moneys and any limitations
26 established by the General Appropriations Act or chapter 216.
27 (5) A pregnant woman for the duration of her pregnancy
28 and for the postpartum period as defined in federal law and
29 rule, or a child under age 1, if either is living in a family
30 that has an income which is at or below 150 percent of the
31 most current federal poverty level, or, effective January 1,
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1 1992, that has an income which is at or below 185 percent of
2 the most current federal poverty level. Such a person is not
3 subject to an assets test. Further, a pregnant woman who
4 applies for eligibility for the Medicaid program through a
5 qualified Medicaid provider must be offered the opportunity,
6 subject to federal rules, to be made presumptively eligible
7 for the Medicaid program.
8 Section 9. Present subsection (10) of section 409.904,
9 Florida Statutes, is amended, present subsections (9), (10),
10 and (11) are renumbered as subsections (10), (11), and (12),
11 respectively, and a new subsection (9) is added to said
12 section, to read:
13 409.904 Optional payments for eligible persons.--The
14 agency may make payments for medical assistance and related
15 services on behalf of the following persons who are determined
16 to be eligible subject to the income, assets, and categorical
17 eligibility tests set forth in federal and state law. Payment
18 on behalf of these Medicaid eligible persons is subject to the
19 availability of moneys and any limitations established by the
20 General Appropriations Act or chapter 216.
21 (9) A pregnant woman for the duration of her pregnancy
22 and for the postpartum period as defined in federal law and
23 regulation, who has an income above 150 percent but not in
24 excess of 185 percent of the federal poverty level. Countable
25 income shall be determined in accordance with state and
26 federal regulation. A pregnant woman who applies for
27 eligibility for the Medicaid program shall be offered the
28 opportunity, subject to federal regulations, to be made
29 presumptively eligible.
30 (11)(10)(a) Eligible women with incomes at or below
31 200 percent of the federal poverty level and under age 65, for
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1 cancer treatment pursuant to the federal Breast and Cervical
2 Cancer Prevention and Treatment Act of 2000, screened through
3 the Mary Brogan National Breast and Cervical Cancer Early
4 Detection Program established under s. 381.93.
5 (b) A woman who has not attained 65 years of age and
6 who has been screened for breast or cervical cancer by a
7 qualified entity under the Mary Brogan Breast and Cervical
8 Cancer Early Detection Program of the Department of Health and
9 needs treatment for breast or cervical cancer and is not
10 otherwise covered under creditable coverage, as defined in s.
11 2701(c) of the Public Health Service Act. For purposes of this
12 subsection, the term "qualified entity" means a county public
13 health department or other entity that has contracted with the
14 Department of Health to provide breast and cervical cancer
15 screening services paid for under this act. In determining the
16 eligibility of such a woman, an assets test is not required. A
17 presumptive eligibility period begins on the date on which all
18 eligibility criteria appear to be met and ends on the date
19 determination is made with respect to the eligibility of such
20 woman for services under the state plan or, in the case of
21 such a woman who does not file an application, by the last day
22 of the month following the month in which the presumptive
23 eligibility determination is made. A woman is eligible until
24 she gains creditable coverage, until treatment is no longer
25 necessary, or until attainment of 65 years of age.
26 Section 10. Effective July 1, 2002, subsection (2) of
27 section 409.9065, Florida Statutes, is amended to read:
28 409.9065 Pharmaceutical expense assistance.--
29 (2) ELIGIBILITY.--Eligibility for the program is
30 limited to those individuals who qualify for limited
31 assistance under the Florida Medicaid program as a result of
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1 being dually eligible for both Medicare and Medicaid, but
2 whose limited assistance or Medicare coverage does not include
3 any pharmacy benefit. To the extent that funds are
4 appropriated, specifically eligible individuals are
5 individuals low-income senior citizens who:
6 (a) Are Florida residents age 65 and over;
7 (b) Have an income:
8 1. Between 90 and 120 percent of the federal poverty
9 level;
10 2. Between 90 and 150 percent of the federal poverty
11 level if the Federal Government increases the federal Medicaid
12 match for persons with incomes between 100 and 150 percent of
13 the federal poverty level; or
14 3. Between 90 percent of the federal poverty level and
15 a level that can be supported with funds provided in the
16 General Appropriations Act for the program offered under this
17 section along with federal matching funds approved by the
18 Federal Government under a Section 1115 waiver. The agency is
19 authorized to submit and implement a federal waiver pursuant
20 to provisions of this subparagraph. The agency shall design a
21 pharmacy benefit that includes annual per-member benefit
22 limits and cost-sharing provisions, and limits enrollment to
23 available appropriations and matching federal funds. Prior to
24 implementing this program, the agency must submit a budget
25 amendment pursuant to chapter 216;
26 (c) Are eligible for both Medicare and Medicaid;
27 (d) Are not enrolled in a Medicare health maintenance
28 organization that provides a pharmacy benefit; and
29 (e) Request to be enrolled in the program.
30
31
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1 Section 11. Subsections (7) and (9) of section
2 409.907, Florida Statutes, as amended by section 6 of chapter
3 2001-377, Laws of Florida, are amended to read:
4 409.907 Medicaid provider agreements.--The agency may
5 make payments for medical assistance and related services
6 rendered to Medicaid recipients only to an individual or
7 entity who has a provider agreement in effect with the agency,
8 who is performing services or supplying goods in accordance
9 with federal, state, and local law, and who agrees that no
10 person shall, on the grounds of handicap, race, color, or
11 national origin, or for any other reason, be subjected to
12 discrimination under any program or activity for which the
13 provider receives payment from the agency.
14 (7) The agency may require, as a condition of
15 participating in the Medicaid program and before entering into
16 the provider agreement, that the provider submit information,
17 in an initial and any required renewal applications,
18 concerning the professional, business, and personal background
19 of the provider and permit an onsite inspection of the
20 provider's service location by agency staff or other personnel
21 designated by the agency to perform this function. After
22 receipt of the fully completed application of a new provider,
23 the agency shall perform onsite inspections of randomly
24 selected providers' service locations, to assist in
25 determining the applicant's ability to provide the services
26 that the applicant is proposing to provide for Medicaid
27 reimbursement. The agency is not required to perform an onsite
28 inspection of a provider or program that is licensed by the
29 agency or the Department of Health or of a provider that
30 provides services under home and community-based services
31 waiver programs or is licensed as a medical foster home by the
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1 Department of Children and Family Services. As a continuing
2 condition of participation in the Medicaid program, a provider
3 shall immediately notify the agency of any current or pending
4 bankruptcy filing. Before entering into the provider
5 agreement, or as a condition of continuing participation in
6 the Medicaid program, the agency may also require that
7 Medicaid providers reimbursed on a fee-for-services basis or
8 fee schedule basis which is not cost-based, post a surety bond
9 not to exceed $50,000 or the total amount billed by the
10 provider to the program during the current or most recent
11 calendar year, whichever is greater. For new providers, the
12 amount of the surety bond shall be determined by the agency
13 based on the provider's estimate of its first year's billing.
14 If the provider's billing during the first year exceeds the
15 bond amount, the agency may require the provider to acquire an
16 additional bond equal to the actual billing level of the
17 provider. A provider's bond shall not exceed $50,000 if a
18 physician or group of physicians licensed under chapter 458,
19 chapter 459, or chapter 460 has a 50 percent or greater
20 ownership interest in the provider or if the provider is an
21 assisted living facility licensed under part III of chapter
22 400. The bonds permitted by this section are in addition to
23 the bonds referenced in s. 400.179(4)(d). If the provider is a
24 corporation, partnership, association, or other entity, the
25 agency may require the provider to submit information
26 concerning the background of that entity and of any principal
27 of the entity, including any partner or shareholder having an
28 ownership interest in the entity equal to 5 percent or
29 greater, and any treating provider who participates in or
30 intends to participate in Medicaid through the entity. The
31 information must include:
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1 (a) Proof of holding a valid license or operating
2 certificate, as applicable, if required by the state or local
3 jurisdiction in which the provider is located or if required
4 by the Federal Government.
5 (b) Information concerning any prior violation, fine,
6 suspension, termination, or other administrative action taken
7 under the Medicaid laws, rules, or regulations of this state
8 or of any other state or the Federal Government; any prior
9 violation of the laws, rules, or regulations relating to the
10 Medicare program; any prior violation of the rules or
11 regulations of any other public or private insurer; and any
12 prior violation of the laws, rules, or regulations of any
13 regulatory body of this or any other state.
14 (c) Full and accurate disclosure of any financial or
15 ownership interest that the provider, or any principal,
16 partner, or major shareholder thereof, may hold in any other
17 Medicaid provider or health care related entity or any other
18 entity that is licensed by the state to provide health or
19 residential care and treatment to persons.
20 (d) If a group provider, identification of all members
21 of the group and attestation that all members of the group are
22 enrolled in or have applied to enroll in the Medicaid program.
23 (9) Upon receipt of a completed, signed, and dated
24 application, and completion of any necessary background
25 investigation and criminal history record check, the agency
26 must either:
27 (a) Enroll the applicant as a Medicaid provider no
28 earlier than the effective date of the approval of the
29 provider application. With respect to providers who were
30 recently granted a change of ownership and those who primarily
31 provide emergency medical services transportation or emergency
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1 services and care pursuant to s. 401.45 or s. 395.1041, and
2 out-of-state providers, upon approval of the provider
3 application, the effective date of approval is considered to
4 be the date the agency receives the provider application; or
5 (b) Deny the application if the agency finds that it
6 is in the best interest of the Medicaid program to do so. The
7 agency may consider the factors listed in subsection (10), as
8 well as any other factor that could affect the effective and
9 efficient administration of the program, including, but not
10 limited to, the applicant's demonstrated ability to provide
11 services, conduct business, and operate a financially viable
12 concern; the current availability of medical care, services,
13 or supplies to recipients, taking into account geographic
14 location and reasonable travel time; the number of providers
15 of the same type already enrolled in the same geographic area;
16 and the credentials, experience, success, and patient outcomes
17 of the provider for the services that it is making application
18 to provide in the Medicaid program. The agency shall deny the
19 application if the agency finds that a provider; any officer,
20 director, agent, managing employee, or affiliated person; or
21 any partner or shareholder having an ownership interest of 5
22 percent or more in the provider if the provider is a
23 corporation, partnership, or other business entity has failed
24 to pay all outstanding fines or overpayments assessed by final
25 order of the agency or final order of the Centers for Medicare
26 and Medicaid Services, unless the provider agrees to a
27 repayment plan that includes withholding Medicaid
28 reimbursement until the amount due is paid in full.
29 Section 12. Section 409.908, Florida Statutes, as
30 amended by section 7 of chapter 2001-377, Laws of Florida, is
31 amended to read:
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1 409.908 Reimbursement of Medicaid providers.--Subject
2 to specific appropriations, the agency shall reimburse
3 Medicaid providers, in accordance with state and federal law,
4 according to methodologies set forth in the rules of the
5 agency and in policy manuals and handbooks incorporated by
6 reference therein. These methodologies may include fee
7 schedules, reimbursement methods based on cost reporting,
8 negotiated fees, competitive bidding pursuant to s. 287.057,
9 and other mechanisms the agency considers efficient and
10 effective for purchasing services or goods on behalf of
11 recipients. If a provider is reimbursed based on cost
12 reporting and submits a cost report late and that cost report
13 would have been used to set a lower reimbursement rate for a
14 rate semester, then the provider's rate for that semester
15 shall be retroactively calculated using the new cost report,
16 and full payment at the recalculated rate shall be affected
17 retroactively. Medicare-granted extensions for filing cost
18 reports, if applicable, shall also apply to Medicaid cost
19 reports. Payment for Medicaid compensable services made on
20 behalf of Medicaid eligible persons is subject to the
21 availability of moneys and any limitations or directions
22 provided for in the General Appropriations Act or chapter 216.
23 Further, nothing in this section shall be construed to prevent
24 or limit the agency from adjusting fees, reimbursement rates,
25 lengths of stay, number of visits, or number of services, or
26 making any other adjustments necessary to comply with the
27 availability of moneys and any limitations or directions
28 provided for in the General Appropriations Act, provided the
29 adjustment is consistent with legislative intent.
30
31
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1 (1) Reimbursement to hospitals licensed under part I
2 of chapter 395 must be made prospectively or on the basis of
3 negotiation.
4 (a) Reimbursement for inpatient care is limited as
5 provided for in s. 409.905(5), except for:
6 1. The raising of rate reimbursement caps, excluding
7 rural hospitals.
8 2. Recognition of the costs of graduate medical
9 education.
10 3. Other methodologies recognized in the General
11 Appropriations Act.
12 4. Hospital inpatient rates shall be reduced by 6
13 percent effective July 1, 2001, and restored effective April
14 1, 2002.
15
16 During the years funds are transferred from the Department of
17 Health, any reimbursement supported by such funds shall be
18 subject to certification by the Department of Health that the
19 hospital has complied with s. 381.0403. The agency is
20 authorized to receive funds from state entities, including,
21 but not limited to, the Department of Health, local
22 governments, and other local political subdivisions, for the
23 purpose of making special exception payments, including
24 federal matching funds, through the Medicaid inpatient
25 reimbursement methodologies. Funds received from state
26 entities or local governments for this purpose shall be
27 separately accounted for and shall not be commingled with
28 other state or local funds in any manner. The agency may
29 certify all local governmental funds used as state match under
30 Title XIX of the Social Security Act, to the extent that the
31 identified local health care provider that is otherwise
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1 entitled to and is contracted to receive such local funds is
2 the benefactor under the state's Medicaid program as
3 determined under the General Appropriations Act and pursuant
4 to an agreement between the Agency for Health Care
5 Administration and the local governmental entity. The local
6 governmental entity shall use a certification form prescribed
7 by the agency. At a minimum, the certification form shall
8 identify the amount being certified and describe the
9 relationship between the certifying local governmental entity
10 and the local health care provider. The agency shall prepare
11 an annual statement of impact which documents the specific
12 activities undertaken during the previous fiscal year pursuant
13 to this paragraph, to be submitted to the Legislature no later
14 than January 1, annually.
15 (b) Reimbursement for hospital outpatient care is
16 limited to $1,500 per state fiscal year per recipient, except
17 for:
18 1. Such care provided to a Medicaid recipient under
19 age 21, in which case the only limitation is medical
20 necessity.
21 2. Renal dialysis services.
22 3. Other exceptions made by the agency.
23
24 The agency is authorized to receive funds from state entities,
25 including, but not limited to, the Department of Health, the
26 Board of Regents, local governments, and other local political
27 subdivisions, for the purpose of making payments, including
28 federal matching funds, through the Medicaid outpatient
29 reimbursement methodologies. Funds received from state
30 entities and local governments for this purpose shall be
31
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1 separately accounted for and shall not be commingled with
2 other state or local funds in any manner.
3 (c) Hospitals that provide services to a
4 disproportionate share of low-income Medicaid recipients, or
5 that participate in the regional perinatal intensive care
6 center program under chapter 383, or that participate in the
7 statutory teaching hospital disproportionate share program may
8 receive additional reimbursement. The total amount of payment
9 for disproportionate share hospitals shall be fixed by the
10 General Appropriations Act. The computation of these payments
11 must be made in compliance with all federal regulations and
12 the methodologies described in ss. 409.911, 409.9112, and
13 409.9113.
14 (d) The agency is authorized to limit inflationary
15 increases for outpatient hospital services as directed by the
16 General Appropriations Act.
17 (2)(a)1. Reimbursement to nursing homes licensed under
18 part II of chapter 400 and state-owned-and-operated
19 intermediate care facilities for the developmentally disabled
20 licensed under chapter 393 must be made prospectively.
21 2. Unless otherwise limited or directed in the General
22 Appropriations Act, reimbursement to hospitals licensed under
23 part I of chapter 395 for the provision of swing-bed nursing
24 home services must be made on the basis of the average
25 statewide nursing home payment, and reimbursement to a
26 hospital licensed under part I of chapter 395 for the
27 provision of skilled nursing services must be made on the
28 basis of the average nursing home payment for those services
29 in the county in which the hospital is located. When a
30 hospital is located in a county that does not have any
31 community nursing homes, reimbursement must be determined by
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1 averaging the nursing home payments, in counties that surround
2 the county in which the hospital is located. Reimbursement to
3 hospitals, including Medicaid payment of Medicare copayments,
4 for skilled nursing services shall be limited to 30 days,
5 unless a prior authorization has been obtained from the
6 agency. Medicaid reimbursement may be extended by the agency
7 beyond 30 days, and approval must be based upon verification
8 by the patient's physician that the patient requires
9 short-term rehabilitative and recuperative services only, in
10 which case an extension of no more than 15 days may be
11 approved. Reimbursement to a hospital licensed under part I of
12 chapter 395 for the temporary provision of skilled nursing
13 services to nursing home residents who have been displaced as
14 the result of a natural disaster or other emergency may not
15 exceed the average county nursing home payment for those
16 services in the county in which the hospital is located and is
17 limited to the period of time which the agency considers
18 necessary for continued placement of the nursing home
19 residents in the hospital.
20 (b) Subject to any limitations or directions provided
21 for in the General Appropriations Act, the agency shall
22 establish and implement a Florida Title XIX Long-Term Care
23 Reimbursement Plan (Medicaid) for nursing home care in order
24 to provide care and services in conformance with the
25 applicable state and federal laws, rules, regulations, and
26 quality and safety standards and to ensure that individuals
27 eligible for medical assistance have reasonable geographic
28 access to such care.
29 1. Changes of ownership or of licensed operator do not
30 qualify for increases in reimbursement rates associated with
31 the change of ownership or of licensed operator. The agency
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1 shall amend the Title XIX Long Term Care Reimbursement Plan to
2 provide that the initial nursing home reimbursement rates, for
3 the operating, patient care, and MAR components, associated
4 with related and unrelated party changes of ownership or
5 licensed operator filed on or after September 1, 2001, are
6 equivalent to the previous owner's reimbursement rate.
7 2. The agency shall amend the long-term care
8 reimbursement plan and cost reporting system to create direct
9 care and indirect care subcomponents of the patient care
10 component of the per diem rate. These two subcomponents
11 together shall equal the patient care component of the per
12 diem rate. Separate cost-based ceilings shall be calculated
13 for each patient care subcomponent. The direct care
14 subcomponent of the per diem rate shall be limited by the
15 cost-based class ceiling, and the indirect care subcomponent
16 shall be limited by the lower of the cost-based class ceiling,
17 by the target rate class ceiling, or by the individual
18 provider target. The agency shall adjust the patient care
19 component effective January 1, 2002. The cost to adjust the
20 direct care subcomponent shall be net of the total funds
21 previously allocated for the case mix add-on. The agency shall
22 make the required changes to the nursing home cost reporting
23 forms to implement this requirement effective January 1, 2002.
24 3. The direct care subcomponent shall include salaries
25 and benefits of direct care staff providing nursing services
26 including registered nurses, licensed practical nurses, and
27 certified nursing assistants who deliver care directly to
28 residents in the nursing home facility. This excludes nursing
29 administration, MDS, and care plan coordinators, staff
30 development, and staffing coordinator.
31
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1 4. All other patient care costs shall be included in
2 the indirect care cost subcomponent of the patient care per
3 diem rate. There shall be no costs directly or indirectly
4 allocated to the direct care subcomponent from a home office
5 or management company.
6 5. On July 1 of each year, the agency shall report to
7 the Legislature direct and indirect care costs, including
8 average direct and indirect care costs per resident per
9 facility and direct care and indirect care salaries and
10 benefits per category of staff member per facility.
11 6. In order to offset the cost of general and
12 professional liability insurance, the agency shall amend Under
13 the plan to allow for, interim rate adjustments shall not be
14 granted to reflect increases in the cost of general or
15 professional liability insurance for nursing homes unless the
16 following criteria are met: have at least a 65 percent
17 Medicaid utilization in the most recent cost report submitted
18 to the agency, and the increase in general or professional
19 liability costs to the facility for the most recent policy
20 period affects the total Medicaid per diem by at least 5
21 percent. This rate adjustment shall not result in the per diem
22 exceeding the class ceiling. This provision shall be
23 implemented to the extent existing appropriations are
24 available. The agency shall adjust the operating component of
25 the per diem rate to allow for an add-on for general and
26 professional liability insurance for nursing facilities,
27 effective July 1, 2002. The add-on shall be calculated by
28 multiplying $500 times the number of Medicaid certified beds
29 divided by the total patient days as reported on the cost
30 report used for the July 2002 rate setting. The total
31 operating cost per diem, including the add-on, shall not be
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1 greater than the provider's actual, inflated operating cost
2 per diem.
3
4 It is the intent of the Legislature that the reimbursement
5 plan achieve the goal of providing access to health care for
6 nursing home residents who require large amounts of care while
7 encouraging diversion services as an alternative to nursing
8 home care for residents who can be served within the
9 community. The agency shall base the establishment of any
10 maximum rate of payment, whether overall or component, on the
11 available moneys as provided for in the General Appropriations
12 Act. The agency may base the maximum rate of payment on the
13 results of scientifically valid analysis and conclusions
14 derived from objective statistical data pertinent to the
15 particular maximum rate of payment.
16 (3) Subject to any limitations or directions provided
17 for in the General Appropriations Act, the following Medicaid
18 services and goods may be reimbursed on a fee-for-service
19 basis. For each allowable service or goods furnished in
20 accordance with Medicaid rules, policy manuals, handbooks, and
21 state and federal law, the payment shall be the amount billed
22 by the provider, the provider's usual and customary charge, or
23 the maximum allowable fee established by the agency, whichever
24 amount is less, with the exception of those services or goods
25 for which the agency makes payment using a methodology based
26 on capitation rates, average costs, or negotiated fees.
27 (a) Advanced registered nurse practitioner services.
28 (b) Birth center services.
29 (c) Chiropractic services.
30 (d) Community mental health services.
31
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1 (e) Dental services, including oral and maxillofacial
2 surgery.
3 (f) Durable medical equipment.
4 (g) Hearing services.
5 (h) Occupational therapy for Medicaid recipients under
6 age 21.
7 (i) Optometric services.
8 (j) Orthodontic services.
9 (k) Personal care for Medicaid recipients under age
10 21.
11 (l) Physical therapy for Medicaid recipients under age
12 21.
13 (m) Physician assistant services.
14 (n) Podiatric services.
15 (o) Portable X-ray services.
16 (p) Private-duty nursing for Medicaid recipients under
17 age 21.
18 (q) Registered nurse first assistant services.
19 (r) Respiratory therapy for Medicaid recipients under
20 age 21.
21 (s) Speech therapy for Medicaid recipients under age
22 21.
23 (t) Visual services.
24 (4) Subject to any limitations or directions provided
25 for in the General Appropriations Act, alternative health
26 plans, health maintenance organizations, and prepaid health
27 plans shall be reimbursed a fixed, prepaid amount negotiated,
28 or competitively bid pursuant to s. 287.057, by the agency and
29 prospectively paid to the provider monthly for each Medicaid
30 recipient enrolled. The amount may not exceed the average
31 amount the agency determines it would have paid, based on
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1 claims experience, for recipients in the same or similar
2 category of eligibility. The agency shall calculate
3 capitation rates on a regional basis and, beginning September
4 1, 1995, shall include age-band differentials in such
5 calculations. Effective July 1, 2001, the cost of exempting
6 statutory teaching hospitals, specialty hospitals, and
7 community hospital education program hospitals from
8 reimbursement ceilings and the cost of special Medicaid
9 payments shall not be included in premiums paid to health
10 maintenance organizations or prepaid health care plans. Each
11 rate semester, the agency shall calculate and publish a
12 Medicaid hospital rate schedule that does not reflect either
13 special Medicaid payments or the elimination of rate
14 reimbursement ceilings, to be used by hospitals and Medicaid
15 health maintenance organizations, in order to determine the
16 Medicaid rate referred to in ss. 409.912(16), 409.9128(5), and
17 641.513(6).
18 (5) An ambulatory surgical center shall be reimbursed
19 the lesser of the amount billed by the provider or the
20 Medicare-established allowable amount for the facility.
21 (6) A provider of early and periodic screening,
22 diagnosis, and treatment services to Medicaid recipients who
23 are children under age 21 shall be reimbursed using an
24 all-inclusive rate stipulated in a fee schedule established by
25 the agency. A provider of the visual, dental, and hearing
26 components of such services shall be reimbursed the lesser of
27 the amount billed by the provider or the Medicaid maximum
28 allowable fee established by the agency.
29 (7) A provider of family planning services shall be
30 reimbursed the lesser of the amount billed by the provider or
31 an all-inclusive amount per type of visit for physicians and
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1 advanced registered nurse practitioners, as established by the
2 agency in a fee schedule.
3 (8) A provider of home-based or community-based
4 services rendered pursuant to a federally approved waiver
5 shall be reimbursed based on an established or negotiated rate
6 for each service. These rates shall be established according
7 to an analysis of the expenditure history and prospective
8 budget developed by each contract provider participating in
9 the waiver program, or under any other methodology adopted by
10 the agency and approved by the Federal Government in
11 accordance with the waiver. Effective July 1, 1996, privately
12 owned and operated community-based residential facilities
13 which meet agency requirements and which formerly received
14 Medicaid reimbursement for the optional intermediate care
15 facility for the mentally retarded service may participate in
16 the developmental services waiver as part of a
17 home-and-community-based continuum of care for Medicaid
18 recipients who receive waiver services.
19 (9) A provider of home health care services or of
20 medical supplies and appliances shall be reimbursed on the
21 basis of competitive bidding or for the lesser of the amount
22 billed by the provider or the agency's established maximum
23 allowable amount, except that, in the case of the rental of
24 durable medical equipment, the total rental payments may not
25 exceed the purchase price of the equipment over its expected
26 useful life or the agency's established maximum allowable
27 amount, whichever amount is less.
28 (10) A hospice shall be reimbursed through a
29 prospective system for each Medicaid hospice patient at
30 Medicaid rates using the methodology established for hospice
31
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1 reimbursement pursuant to Title XVIII of the federal Social
2 Security Act.
3 (11) A provider of independent laboratory services
4 shall be reimbursed on the basis of competitive bidding or for
5 the least of the amount billed by the provider, the provider's
6 usual and customary charge, or the Medicaid maximum allowable
7 fee established by the agency.
8 (12)(a) A physician shall be reimbursed the lesser of
9 the amount billed by the provider or the Medicaid maximum
10 allowable fee established by the agency.
11 (b) The agency shall adopt a fee schedule, subject to
12 any limitations or directions provided for in the General
13 Appropriations Act, based on a resource-based relative value
14 scale for pricing Medicaid physician services. Under this fee
15 schedule, physicians shall be paid a dollar amount for each
16 service based on the average resources required to provide the
17 service, including, but not limited to, estimates of average
18 physician time and effort, practice expense, and the costs of
19 professional liability insurance. The fee schedule shall
20 provide increased reimbursement for preventive and primary
21 care services and lowered reimbursement for specialty services
22 by using at least two conversion factors, one for cognitive
23 services and another for procedural services. The fee
24 schedule shall not increase total Medicaid physician
25 expenditures unless moneys are available, and shall be phased
26 in over a 2-year period beginning on July 1, 1994. The Agency
27 for Health Care Administration shall seek the advice of a
28 16-member advisory panel in formulating and adopting the fee
29 schedule. The panel shall consist of Medicaid physicians
30 licensed under chapters 458 and 459 and shall be composed of
31
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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
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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
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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.
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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
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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
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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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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. Subsection (1) of section 409.911, Florida
18 Statutes, is amended to read:
19 409.911 Disproportionate share program.--Subject to
20 specific allocations established within the General
21 Appropriations Act and any limitations established pursuant to
22 chapter 216, the agency shall distribute, pursuant to this
23 section, moneys to hospitals providing a disproportionate
24 share of Medicaid or charity care services by making quarterly
25 Medicaid payments as required. Notwithstanding the provisions
26 of s. 409.915, counties are exempt from contributing toward
27 the cost of this special reimbursement for hospitals serving a
28 disproportionate share of low-income patients.
29 (1) Definitions.--As used in this section, and s.
30 409.9112, and the Florida Hospital Uniform Reporting System
31 manual:
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1 (a) "Adjusted patient days" means the sum of acute
2 care patient days and intensive care patient days as reported
3 to the Agency for Health Care Administration, divided by the
4 ratio of inpatient revenues generated from acute, intensive,
5 ambulatory, and ancillary patient services to gross revenues.
6 (b) "Actual audited data" or "actual audited
7 experience" means data reported to the Agency for Health Care
8 Administration which has been audited in accordance with
9 generally accepted auditing standards by the agency or
10 representatives under contract with the agency.
11 (c) "Base Medicaid per diem" means the hospital's
12 Medicaid per diem rate initially established by the Agency for
13 Health Care Administration on January 1, 1999. The base
14 Medicaid per diem rate shall not include any additional per
15 diem increases received as a result of the disproportionate
16 share distribution.
17 (d) "Charity care" or "uncompensated charity care"
18 means that portion of hospital charges reported to the Agency
19 for Health Care Administration for which there is no
20 compensation, other than restricted or unrestricted revenues
21 provided to a hospital by local governments or tax districts
22 regardless of the method of payment, for care provided to a
23 patient whose family income for the 12 months preceding the
24 determination is less than or equal to 200 percent of the
25 federal poverty level, unless the amount of hospital charges
26 due from the patient exceeds 25 percent of the annual family
27 income. However, in no case shall the hospital charges for a
28 patient whose family income exceeds four times the federal
29 poverty level for a family of four be considered charity.
30 (e) "Charity care days" means the sum of the
31 deductions from revenues for charity care minus 50 percent of
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1 restricted and unrestricted revenues provided to a hospital by
2 local governments or tax districts, divided by gross revenues
3 per adjusted patient day.
4 (f) "Disproportionate share percentage" means a rate
5 of increase in the Medicaid per diem rate as calculated under
6 this section.
7 (g) "Hospital" means a health care institution
8 licensed as a hospital pursuant to chapter 395, but does not
9 include ambulatory surgical centers.
10 (h) "Medicaid days" means the number of actual days
11 attributable to Medicaid patients as determined by the Agency
12 for Health Care Administration.
13 Section 14. Subsection (7) of section 409.9116,
14 Florida Statutes, is amended to read:
15 409.9116 Disproportionate share/financial assistance
16 program for rural hospitals.--In addition to the payments made
17 under s. 409.911, the Agency for Health Care Administration
18 shall administer a federally matched disproportionate share
19 program and a state-funded financial assistance program for
20 statutory rural hospitals. The agency shall make
21 disproportionate share payments to statutory rural hospitals
22 that qualify for such payments and financial assistance
23 payments to statutory rural hospitals that do not qualify for
24 disproportionate share payments. The disproportionate share
25 program payments shall be limited by and conform with federal
26 requirements. Funds shall be distributed quarterly in each
27 fiscal year for which an appropriation is made.
28 Notwithstanding the provisions of s. 409.915, counties are
29 exempt from contributing toward the cost of this special
30 reimbursement for hospitals serving a disproportionate share
31 of low-income patients.
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1 (7) This section applies only to hospitals that were
2 defined as statutory rural hospitals, or their
3 successor-in-interest hospital, prior to July 1, 1999 1998.
4 Any additional hospital that is defined as a statutory rural
5 hospital, or its successor-in-interest hospital, on or after
6 July 1, 1999 1998, is not eligible for programs under this
7 section unless additional funds are appropriated each fiscal
8 year specifically to the rural hospital disproportionate share
9 and financial assistance programs in an amount necessary to
10 prevent any hospital, or its successor-in-interest hospital,
11 eligible for the programs prior to July 1, 1999 1998, from
12 incurring a reduction in payments because of the eligibility
13 of an additional hospital to participate in the programs. A
14 hospital, or its successor-in-interest hospital, which
15 received funds pursuant to this section before July 1, 1999
16 1998, and which qualifies under s. 395.602(2)(e), shall be
17 included in the programs under this section and is not
18 required to seek additional appropriations under this
19 subsection.
20 Section 15. Subsection (7) of section 409.91195,
21 Florida Statutes, is amended to read:
22 409.91195 Medicaid Pharmaceutical and Therapeutics
23 Committee.--There is created a Medicaid Pharmaceutical and
24 Therapeutics Committee within the Agency for Health Care
25 Administration for the purpose of developing a preferred drug
26 formulary pursuant to 42 U.S.C. s. 1396r-8.
27 (7) The committee shall ensure that interested
28 parties, including pharmaceutical manufacturers agreeing to
29 provide a supplemental rebate as outlined in this chapter,
30 have an opportunity to present public testimony to the
31 committee with information or evidence supporting inclusion of
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1 a product on the preferred drug list. Such public testimony
2 shall occur prior to any recommendations made by the committee
3 for inclusion or exclusion from the preferred drug list. Upon
4 timely notice, the agency shall ensure that any drug that has
5 been approved or had any of its particular uses approved by
6 the United States Food and Drug Administration under a
7 priority review classification will be reviewed by the
8 Medicaid Pharmaceutical and Therapeutics Committee at the next
9 regularly scheduled meeting. To the extent possible, upon
10 notice by a manufacturer the agency shall also schedule a
11 product review for any new product at the next regularly
12 scheduled Medicaid Pharmaceutical and Therapeutics Committee.
13 Section 16. Paragraph (b) of subsection (3) and
14 paragraph (b) of subsection (13) of section 409.912, Florida
15 Statutes, are amended to read:
16 409.912 Cost-effective purchasing of health care.--The
17 agency shall purchase goods and services for Medicaid
18 recipients in the most cost-effective manner consistent with
19 the delivery of quality medical care. The agency shall
20 maximize the use of prepaid per capita and prepaid aggregate
21 fixed-sum basis services when appropriate and other
22 alternative service delivery and reimbursement methodologies,
23 including competitive bidding pursuant to s. 287.057, designed
24 to facilitate the cost-effective purchase of a case-managed
25 continuum of care. The agency shall also require providers to
26 minimize the exposure of recipients to the need for acute
27 inpatient, custodial, and other institutional care and the
28 inappropriate or unnecessary use of high-cost services. The
29 agency may establish prior authorization requirements for
30 certain populations of Medicaid beneficiaries, certain drug
31 classes, or particular drugs to prevent fraud, abuse, overuse,
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1 and possible dangerous drug interactions. The Pharmaceutical
2 and Therapeutics Committee shall make recommendations to the
3 agency on drugs for which prior authorization is required. The
4 agency shall inform the Pharmaceutical and Therapeutics
5 Committee of its decisions regarding drugs subject to prior
6 authorization.
7 (3) The agency may contract with:
8 (b) An entity that is providing comprehensive
9 behavioral health care services to certain Medicaid recipients
10 through a capitated, prepaid arrangement pursuant to the
11 federal waiver provided for by s. 409.905(5). Such an entity
12 must be licensed under chapter 624, chapter 636, or chapter
13 641 and must possess the clinical systems and operational
14 competence to manage risk and provide comprehensive behavioral
15 health care to Medicaid recipients. As used in this paragraph,
16 the term "comprehensive behavioral health care services" means
17 covered mental health and substance abuse treatment services
18 that are available to Medicaid recipients. The secretary of
19 the Department of Children and Family Services shall approve
20 provisions of procurements related to children in the
21 department's care or custody prior to enrolling such children
22 in a prepaid behavioral health plan. Any contract awarded
23 under this paragraph must be competitively procured. In
24 developing the behavioral health care prepaid plan procurement
25 document, the agency shall ensure that the procurement
26 document requires the contractor to develop and implement a
27 plan to ensure compliance with s. 394.4574 related to services
28 provided to residents of licensed assisted living facilities
29 that hold a limited mental health license. The agency must
30 ensure that Medicaid recipients have available the choice of
31 at least two managed care plans for their behavioral health
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1 care services. To ensure unimpaired access to behavioral
2 health care services by Medicaid recipients, all contracts
3 issued pursuant to this paragraph shall require 80 percent of
4 the capitation paid to the managed care plan, including health
5 maintenance organizations, to be expended for the provision of
6 behavioral health care services. In the event the managed care
7 plan expends less than 80 percent of the capitation paid
8 pursuant to this paragraph for the provision of behavioral
9 health care services, the difference shall be returned to the
10 agency. The agency shall provide the managed care plan with a
11 certification letter indicating the amount of capitation paid
12 during each calendar year for the provision of behavioral
13 health care services pursuant to this section. The agency may
14 reimburse for substance-abuse-treatment services on a
15 fee-for-service basis until the agency finds that adequate
16 funds are available for capitated, prepaid arrangements.
17 1. By January 1, 2001, the agency shall modify the
18 contracts with the entities providing comprehensive inpatient
19 and outpatient mental health care services to Medicaid
20 recipients in Hillsborough, Highlands, Hardee, Manatee, and
21 Polk Counties, to include substance-abuse-treatment services.
22 2. By December 31, 2001, the agency shall contract
23 with entities providing comprehensive behavioral health care
24 services to Medicaid recipients through capitated, prepaid
25 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
26 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
27 and Walton Counties. The agency may contract with entities
28 providing comprehensive behavioral health care services to
29 Medicaid recipients through capitated, prepaid arrangements in
30 Alachua County. The agency may determine if Sarasota County
31
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1 shall be included as a separate catchment area or included in
2 any other agency geographic area.
3 3. Children residing in a Department of Juvenile
4 Justice residential program approved as a Medicaid behavioral
5 health overlay services provider shall not be included in a
6 behavioral health care prepaid health plan pursuant to this
7 paragraph.
8 4. In converting to a prepaid system of delivery, the
9 agency shall in its procurement document require an entity
10 providing comprehensive behavioral health care services to
11 prevent the displacement of indigent care patients by
12 enrollees in the Medicaid prepaid health plan providing
13 behavioral health care services from facilities receiving
14 state funding to provide indigent behavioral health care, to
15 facilities licensed under chapter 395 which do not receive
16 state funding for indigent behavioral health care, or
17 reimburse the unsubsidized facility for the cost of behavioral
18 health care provided to the displaced indigent care patient.
19 5. Traditional community mental health providers under
20 contract with the Department of Children and Family Services
21 pursuant to part IV of chapter 394 and inpatient mental health
22 providers licensed pursuant to chapter 395 must be offered an
23 opportunity to accept or decline a contract to participate in
24 any provider network for prepaid behavioral health services.
25 (13)
26 (b) The responsibility of the agency under this
27 subsection shall include the development of capabilities to
28 identify actual and optimal practice patterns; patient and
29 provider educational initiatives; methods for determining
30 patient compliance with prescribed treatments; fraud, waste,
31
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1 and abuse prevention and detection programs; and beneficiary
2 case management programs.
3 1. The practice pattern identification program shall
4 evaluate practitioner prescribing patterns based on national
5 and regional practice guidelines, comparing practitioners to
6 their peer groups. The agency and its Drug Utilization Review
7 Board shall consult with a panel of practicing health care
8 professionals consisting of the following: the Speaker of the
9 House of Representatives and the President of the Senate shall
10 each appoint three physicians licensed under chapter 458 or
11 chapter 459; and the Governor shall appoint two pharmacists
12 licensed under chapter 465 and one dentist licensed under
13 chapter 466 who is an oral surgeon. Terms of the panel members
14 shall expire at the discretion of the appointing official. The
15 panel shall begin its work by August 1, 1999, regardless of
16 the number of appointments made by that date. The advisory
17 panel shall be responsible for evaluating treatment guidelines
18 and recommending ways to incorporate their use in the practice
19 pattern identification program. Practitioners who are
20 prescribing inappropriately or inefficiently, as determined by
21 the agency, may have their prescribing of certain drugs
22 subject to prior authorization.
23 2. The agency shall also develop educational
24 interventions designed to promote the proper use of
25 medications by providers and beneficiaries.
26 3. The agency shall implement a pharmacy fraud, waste,
27 and abuse initiative that may include a surety bond or letter
28 of credit requirement for participating pharmacies, enhanced
29 provider auditing practices, the use of additional fraud and
30 abuse software, recipient management programs for
31 beneficiaries inappropriately using their benefits, and other
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1 steps that will eliminate provider and recipient fraud, waste,
2 and abuse. The initiative shall address enforcement efforts to
3 reduce the number and use of counterfeit prescriptions.
4 4. By September 30, 2002, the agency shall contract
5 with an entity in the state to implement a wireless handheld
6 clinical pharmacology drug information database for
7 practitioners. The initiative shall be designed to enhance the
8 agency's efforts to reduce fraud, abuse, and errors in the
9 prescription drug benefit program and to otherwise further the
10 intent of this paragraph.
11 5.4. The agency may apply for any federal waivers
12 needed to implement this paragraph.
13 Section 17. Paragraphs (f) and (k) of subsection (2)
14 of section 409.9122, Florida Statutes, as amended by section
15 11 of chapter 2001-377, Laws of Florida, are amended to read:
16 409.9122 Mandatory Medicaid managed care enrollment;
17 programs and procedures.--
18 (2)
19 (f) When a Medicaid recipient does not choose a
20 managed care plan or MediPass provider, the agency shall
21 assign the Medicaid recipient to a managed care plan or
22 MediPass provider. Medicaid recipients who are subject to
23 mandatory assignment but who fail to make a choice shall be
24 assigned to managed care plans or provider service networks
25 until an equal enrollment of 45 50 percent in MediPass and 55
26 50 percent in managed care plans is achieved. Once that equal
27 enrollment is achieved, the assignments shall be divided in
28 order to maintain an equal enrollment in MediPass and managed
29 care plans which is in a 45 percent and 55 percent proportion,
30 respectively. Thereafter, assignment of Medicaid recipients
31 who fail to make a choice shall be based proportionally on the
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1 preferences of recipients who have made a choice in the
2 previous period. Such proportions shall be revised at least
3 quarterly to reflect an update of the preferences of Medicaid
4 recipients. The agency shall also disproportionately assign
5 Medicaid-eligible children in families who are required to but
6 have failed to make a choice of managed care plan or MediPass
7 for their child and who are to be assigned to the MediPass
8 program or managed care plans to children's networks as
9 described in s. 409.912(3)(g) and where available. The
10 disproportionate assignment of children to children's networks
11 shall be made until the agency has determined that the
12 children's networks have sufficient numbers to be economically
13 operated. In geographic areas where the agency is contracting
14 for the provision of comprehensive behavioral health services
15 through a capitated prepaid arrangement, recipients who fail
16 to make a choice shall be assigned equally to MediPass or a
17 managed care plan. For purposes of this paragraph, when
18 referring to assignment, the term "managed care plans"
19 includes exclusive provider organizations, provider service
20 networks, Children's Medical Services primary and specialty
21 networks, minority physician networks, and pediatric emergency
22 department diversion programs authorized by this chapter or
23 the General Appropriations Act. When making assignments, the
24 agency shall take into account the following criteria:
25 1. A managed care plan has sufficient network capacity
26 to meet the need of members.
27 2. The managed care plan or MediPass has previously
28 enrolled the recipient as a member, or one of the managed care
29 plan's primary care providers or MediPass providers has
30 previously provided health care to the recipient.
31
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1 3. The agency has knowledge that the member has
2 previously expressed a preference for a particular managed
3 care plan or MediPass provider as indicated by Medicaid
4 fee-for-service claims data, but has failed to make a choice.
5 4. The managed care plan's or MediPass primary care
6 providers are geographically accessible to the recipient's
7 residence.
8 (k) When a Medicaid recipient does not choose a
9 managed care plan or MediPass provider, the agency shall
10 assign the Medicaid recipient to a managed care plan, except
11 in those counties in which there are fewer than two managed
12 care plans accepting Medicaid enrollees, in which case
13 assignment shall be to a managed care plan or a MediPass
14 provider. Medicaid recipients in counties with fewer than two
15 managed care plans accepting Medicaid enrollees who are
16 subject to mandatory assignment but who fail to make a choice
17 shall be assigned to managed care plans until an equal
18 enrollment of 45 50 percent in MediPass and provider service
19 networks and 55 50 percent in managed care plans is achieved.
20 Once that equal enrollment is achieved, the assignments shall
21 be divided in order to maintain an equal enrollment in
22 MediPass and managed care plans which is in a 45 percent and
23 55 percent proportion, respectively. In geographic areas where
24 the agency is contracting for the provision of comprehensive
25 behavioral health services through a capitated prepaid
26 arrangement, recipients who fail to make a choice shall be
27 assigned equally to MediPass or a managed care plan. For
28 purposes of this paragraph, when referring to assignment, the
29 term "managed care plans" includes exclusive provider
30 organizations, provider service networks, Children's Medical
31 Services primary and specialty networks, minority physician
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1 networks, and pediatric emergency department diversion
2 programs authorized by this chapter or the General
3 Appropriations Act. When making assignments, the agency shall
4 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 18. Paragraph (l) is added to subsection (2)
22 of section 409.9122, Florida Statutes, to read:
23 409.9122 Mandatory Medicaid managed care enrollment;
24 programs and procedures.--
25 (2)
26 (l) Notwithstanding the provisions of chapter 287, the
27 agency may, at its discretion, renew cost-effective contracts
28 for choice counseling services once or more for such periods
29 as the agency may decide. However, all such renewals may not
30 combine to exceed a total period longer than the term of the
31 original contract.
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1 Section 19. Section 409.913, Florida Statutes, as
2 amended by section 12 of chapter 2001-377, Laws of Florida, is
3 amended to read:
4 409.913 Oversight of the integrity of the Medicaid
5 program.--The agency shall operate a program to oversee the
6 activities of Florida Medicaid recipients, and providers and
7 their representatives, to ensure that fraudulent and abusive
8 behavior and neglect of recipients occur to the minimum extent
9 possible, and to recover overpayments and impose sanctions as
10 appropriate. Beginning January 1, 2003, and each year
11 thereafter, the agency and the Medicaid Fraud Control Unit of
12 the Department of Legal Affairs shall submit a joint report to
13 the Legislature documenting the effectiveness of the state's
14 efforts to control Medicaid fraud and abuse.
15 (1) For the purposes of this section, the term:
16 (a) "Abuse" means:
17 1. Provider practices that are inconsistent with
18 generally accepted business or medical practices and that
19 result in an unnecessary cost to the Medicaid program or in
20 reimbursement for goods or services that are not medically
21 necessary or that fail to meet professionally recognized
22 standards for health care.
23 2. Recipient practices that result in unnecessary cost
24 to the Medicaid program.
25 (b) "Complaint" means an allegation that fraud, abuse,
26 or an overpayment has occurred.
27 (c)(b) "Fraud" means an intentional deception or
28 misrepresentation made by a person with the knowledge that the
29 deception results in unauthorized benefit to herself or
30 himself or another person. The term includes any act that
31 constitutes fraud under applicable federal or state law.
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1 (d)(c) "Medical necessity" or "medically necessary"
2 means any goods or services necessary to palliate the effects
3 of a terminal condition, or to prevent, diagnose, correct,
4 cure, alleviate, or preclude deterioration of a condition that
5 threatens life, causes pain or suffering, or results in
6 illness or infirmity, which goods or services are provided in
7 accordance with generally accepted standards of medical
8 practice. For purposes of determining Medicaid reimbursement,
9 the agency is the final arbiter of medical necessity.
10 Determinations of medical necessity must be made by a licensed
11 physician employed by or under contract with the agency and
12 must be based upon information available at the time the goods
13 or services are provided.
14 (e)(d) "Overpayment" includes any amount that is not
15 authorized to be paid by the Medicaid program whether paid as
16 a result of inaccurate or improper cost reporting, improper
17 claiming, unacceptable practices, fraud, abuse, or mistake.
18 (f)(e) "Person" means any natural person, corporation,
19 partnership, association, clinic, group, or other entity,
20 whether or not such person is enrolled in the Medicaid program
21 or is a provider of health care.
22 (2) The agency shall conduct, or cause to be conducted
23 by contract or otherwise, reviews, investigations, analyses,
24 audits, or any combination thereof, to determine possible
25 fraud, abuse, overpayment, or recipient neglect in the
26 Medicaid program and shall report the findings of any
27 overpayments in audit reports as appropriate.
28 (3) The agency may conduct, or may contract for,
29 prepayment review of provider claims to ensure cost-effective
30 purchasing, billing, and provision of care to Medicaid
31 recipients. Such prepayment reviews may be conducted as
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1 determined appropriate by the agency, without any suspicion or
2 allegation of fraud, abuse, or neglect.
3 (4) Any suspected criminal violation identified by the
4 agency must be referred to the Medicaid Fraud Control Unit of
5 the Office of the Attorney General for investigation. The
6 agency and the Attorney General shall enter into a memorandum
7 of understanding, which must include, but need not be limited
8 to, a protocol for regularly sharing information and
9 coordinating casework. The protocol must establish a
10 procedure for the referral by the agency of cases involving
11 suspected Medicaid fraud to the Medicaid Fraud Control Unit
12 for investigation, and the return to the agency of those cases
13 where investigation determines that administrative action by
14 the agency is appropriate.
15 (5) A Medicaid provider is subject to having goods and
16 services that are paid for by the Medicaid program reviewed by
17 an appropriate peer-review organization designated by the
18 agency. The written findings of the applicable peer-review
19 organization are admissible in any court or administrative
20 proceeding as evidence of medical necessity or the lack
21 thereof.
22 (6) Any notice required to be given to a provider
23 under this section is presumed to be sufficient notice if sent
24 to the address last shown on the provider enrollment file. It
25 is the responsibility of the provider to furnish and keep the
26 agency informed of the provider's current address. United
27 States Postal Service proof of mailing or certified or
28 registered mailing of such notice to the provider at the
29 address shown on the provider enrollment file constitutes
30 sufficient proof of notice. Any notice required to be given to
31
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1 the agency by this section must be sent to the agency at an
2 address designated by rule.
3 (7) When presenting a claim for payment under the
4 Medicaid program, a provider has an affirmative duty to
5 supervise the provision of, and be responsible for, goods and
6 services claimed to have been provided, to supervise and be
7 responsible for preparation and submission of the claim, and
8 to present a claim that is true and accurate and that is for
9 goods and services that:
10 (a) Have actually been furnished to the recipient by
11 the provider prior to submitting the claim.
12 (b) Are Medicaid-covered goods or services that are
13 medically necessary.
14 (c) Are of a quality comparable to those furnished to
15 the general public by the provider's peers.
16 (d) Have not been billed in whole or in part to a
17 recipient or a recipient's responsible party, except for such
18 copayments, coinsurance, or deductibles as are authorized by
19 the agency.
20 (e) Are provided in accord with applicable provisions
21 of all Medicaid rules, regulations, handbooks, and policies
22 and in accordance with federal, state, and local law.
23 (f) Are documented by records made at the time the
24 goods or services were provided, demonstrating the medical
25 necessity for the goods or services rendered. Medicaid goods
26 or services are excessive or not medically necessary unless
27 both the medical basis and the specific need for them are
28 fully and properly documented in the recipient's medical
29 record.
30 (8) A Medicaid provider shall retain medical,
31 professional, financial, and business records pertaining to
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1 services and goods furnished to a Medicaid recipient and
2 billed to Medicaid for a period of 5 years after the date of
3 furnishing such services or goods. The agency may investigate,
4 review, or analyze such records, which must be made available
5 during normal business hours. However, 24-hour notice must be
6 provided if patient treatment would be disrupted. The provider
7 is responsible for furnishing to the agency, and keeping the
8 agency informed of the location of, the provider's
9 Medicaid-related records. The authority of the agency to
10 obtain Medicaid-related records from a provider is neither
11 curtailed nor limited during a period of litigation between
12 the agency and the provider.
13 (9) Payments for the services of billing agents or
14 persons participating in the preparation of a Medicaid claim
15 shall not be based on amounts for which they bill nor based on
16 the amount a provider receives from the Medicaid program.
17 (10) The agency may require repayment for
18 inappropriate, medically unnecessary, or excessive goods or
19 services from the person furnishing them, the person under
20 whose supervision they were furnished, or the person causing
21 them to be furnished.
22 (11) The complaint and all information obtained
23 pursuant to an investigation of a Medicaid provider, or the
24 authorized representative or agent of a provider, relating to
25 an allegation of fraud, abuse, or neglect are confidential and
26 exempt from the provisions of s. 119.07(1):
27 (a) Until the agency takes final agency action with
28 respect to the provider and requires repayment of any
29 overpayment, or imposes an administrative sanction;
30 (b) Until the Attorney General refers the case for
31 criminal prosecution;
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1 (c) Until 10 days after the complaint is determined
2 without merit; or
3 (d) At all times if the complaint or information is
4 otherwise protected by law.
5 (12) The agency may terminate participation of a
6 Medicaid provider in the Medicaid program and may seek civil
7 remedies or impose other administrative sanctions against a
8 Medicaid provider, if the provider has been:
9 (a) Convicted of a criminal offense related to the
10 delivery of any health care goods or services, including the
11 performance of management or administrative functions relating
12 to the delivery of health care goods or services;
13 (b) Convicted of a criminal offense under federal law
14 or the law of any state relating to the practice of the
15 provider's profession; or
16 (c) Found by a court of competent jurisdiction to have
17 neglected or physically abused a patient in connection with
18 the delivery of health care goods or services.
19 (13) If the provider has been suspended or terminated
20 from participation in the Medicaid program or the Medicare
21 program by the Federal Government or any state, the agency
22 must immediately suspend or terminate, as appropriate, the
23 provider's participation in the Florida Medicaid program for a
24 period no less than that imposed by the Federal Government or
25 any other state, and may not enroll such provider in the
26 Florida Medicaid program while such foreign suspension or
27 termination remains in effect. This sanction is in addition
28 to all other remedies provided by law.
29 (14) The agency may seek any remedy provided by law,
30 including, but not limited to, the remedies provided in
31 subsections (12) and (15) and s. 812.035, if:
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1 (a) The provider's license has not been renewed, or
2 has been revoked, suspended, or terminated, for cause, by the
3 licensing agency of any state;
4 (b) The provider has failed to make available or has
5 refused access to Medicaid-related records to an auditor,
6 investigator, or other authorized employee or agent of the
7 agency, the Attorney General, a state attorney, or the Federal
8 Government;
9 (c) The provider has not furnished or has failed to
10 make available such Medicaid-related records as the agency has
11 found necessary to determine whether Medicaid payments are or
12 were due and the amounts thereof;
13 (d) The provider has failed to maintain medical
14 records made at the time of service, or prior to service if
15 prior authorization is required, demonstrating the necessity
16 and appropriateness of the goods or services rendered;
17 (e) The provider is not in compliance with provisions
18 of Medicaid provider publications that have been adopted by
19 reference as rules in the Florida Administrative Code; with
20 provisions of state or federal laws, rules, or regulations;
21 with provisions of the provider agreement between the agency
22 and the provider; or with certifications found on claim forms
23 or on transmittal forms for electronically submitted claims
24 that are submitted by the provider or authorized
25 representative, as such provisions apply to the Medicaid
26 program;
27 (f) The provider or person who ordered or prescribed
28 the care, services, or supplies has furnished, or ordered the
29 furnishing of, goods or services to a recipient which are
30 inappropriate, unnecessary, excessive, or harmful to the
31 recipient or are of inferior quality;
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1 (g) The provider has demonstrated a pattern of failure
2 to provide goods or services that are medically necessary;
3 (h) The provider or an authorized representative of
4 the provider, or a person who ordered or prescribed the goods
5 or services, has submitted or caused to be submitted false or
6 a pattern of erroneous Medicaid claims that have resulted in
7 overpayments to a provider or that exceed those to which the
8 provider was entitled under the Medicaid program;
9 (i) The provider or an authorized representative of
10 the provider, or a person who has ordered or prescribed the
11 goods or services, has submitted or caused to be submitted a
12 Medicaid provider enrollment application, a request for prior
13 authorization for Medicaid services, a drug exception request,
14 or a Medicaid cost report that contains materially false or
15 incorrect information;
16 (j) The provider or an authorized representative of
17 the provider has collected from or billed a recipient or a
18 recipient's responsible party improperly for amounts that
19 should not have been so collected or billed by reason of the
20 provider's billing the Medicaid program for the same service;
21 (k) The provider or an authorized representative of
22 the provider has included in a cost report costs that are not
23 allowable under a Florida Title XIX reimbursement plan, after
24 the provider or authorized representative had been advised in
25 an audit exit conference or audit report that the costs were
26 not allowable;
27 (l) The provider is charged by information or
28 indictment with fraudulent billing practices. The sanction
29 applied for this reason is limited to suspension of the
30 provider's participation in the Medicaid program for the
31
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1 duration of the indictment unless the provider is found guilty
2 pursuant to the information or indictment;
3 (m) The provider or a person who has ordered, or
4 prescribed the goods or services is found liable for negligent
5 practice resulting in death or injury to the provider's
6 patient;
7 (n) The provider fails to demonstrate that it had
8 available during a specific audit or review period sufficient
9 quantities of goods, or sufficient time in the case of
10 services, to support the provider's billings to the Medicaid
11 program;
12 (o) The provider has failed to comply with the notice
13 and reporting requirements of s. 409.907; or
14 (p) The agency has received reliable information of
15 patient abuse or neglect or of any act prohibited by s.
16 409.920; or.
17 (q) The provider has failed to comply with an
18 agreed-upon repayment schedule.
19 (15) The agency may impose any of the following
20 sanctions or disincentives on a provider or a person for any
21 of the acts described in subsection (14):
22 (a) Suspension for a specific period of time of not
23 more than 1 year.
24 (b) Termination for a specific period of time of from
25 more than 1 year to 20 years.
26 (c) Imposition of a fine of up to $5,000 for each
27 violation. Each day that an ongoing violation continues, such
28 as refusing to furnish Medicaid-related records or refusing
29 access to records, is considered, for the purposes of this
30 section, to be a separate violation. Each instance of
31 improper billing of a Medicaid recipient; each instance of
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1 including an unallowable cost on a hospital or nursing home
2 Medicaid cost report after the provider or authorized
3 representative has been advised in an audit exit conference or
4 previous audit report of the cost unallowability; each
5 instance of furnishing a Medicaid recipient goods or
6 professional services that are inappropriate or of inferior
7 quality as determined by competent peer judgment; each
8 instance of knowingly submitting a materially false or
9 erroneous Medicaid provider enrollment application, request
10 for prior authorization for Medicaid services, drug exception
11 request, or cost report; each instance of inappropriate
12 prescribing of drugs for a Medicaid recipient as determined by
13 competent peer judgment; and each false or erroneous Medicaid
14 claim leading to an overpayment to a provider is considered,
15 for the purposes of this section, to be a separate violation.
16 (d) Immediate suspension, if the agency has received
17 information of patient abuse or neglect or of any act
18 prohibited by s. 409.920. Upon suspension, the agency must
19 issue an immediate final order under s. 120.569(2)(n).
20 (e) A fine, not to exceed $10,000, for a violation of
21 paragraph (14)(i).
22 (f) Imposition of liens against provider assets,
23 including, but not limited to, financial assets and real
24 property, not to exceed the amount of fines or recoveries
25 sought, upon entry of an order determining that such moneys
26 are due or recoverable.
27 (g) Prepayment reviews of claims for a specified
28 period of time.
29 (h) Followup reviews of providers every 6 months until
30 the agency is satisfied that the deficiencies have been
31 corrected.
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1 (i) Corrective action plans that would remain in
2 effect for providers for up to 3 years and that would be
3 monitored by the agency every 6 months while in effect.
4 (j)(g) Other remedies as permitted by law to effect
5 the recovery of a fine or overpayment.
6 (16) In determining the appropriate administrative
7 sanction to be applied, or the duration of any suspension or
8 termination, the agency shall consider:
9 (a) The seriousness and extent of the violation or
10 violations.
11 (b) Any prior history of violations by the provider
12 relating to the delivery of health care programs which
13 resulted in either a criminal conviction or in administrative
14 sanction or penalty.
15 (c) Evidence of continued violation within the
16 provider's management control of Medicaid statutes, rules,
17 regulations, or policies after written notification to the
18 provider of improper practice or instance of violation.
19 (d) The effect, if any, on the quality of medical care
20 provided to Medicaid recipients as a result of the acts of the
21 provider.
22 (e) Any action by a licensing agency respecting the
23 provider in any state in which the provider operates or has
24 operated.
25 (f) The apparent impact on access by recipients to
26 Medicaid services if the provider is suspended or terminated,
27 in the best judgment of the agency.
28
29 The agency shall document the basis for all sanctioning
30 actions and recommendations.
31
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1 (17) The agency may take action to sanction, suspend,
2 or terminate a particular provider working for a group
3 provider, and may suspend or terminate Medicaid participation
4 at a specific location, rather than or in addition to taking
5 action against an entire group.
6 (18) The agency shall establish a process for
7 conducting followup reviews of a sampling of providers who
8 have a history of overpayment under the Medicaid program.
9 This process must consider the magnitude of previous fraud or
10 abuse and the potential effect of continued fraud or abuse on
11 Medicaid costs.
12 (19) In making a determination of overpayment to a
13 provider, the agency must use accepted and valid auditing,
14 accounting, analytical, statistical, or peer-review methods,
15 or combinations thereof. Appropriate statistical methods may
16 include, but are not limited to, sampling and extension to the
17 population, parametric and nonparametric statistics, tests of
18 hypotheses, and other generally accepted statistical methods.
19 Appropriate analytical methods may include, but are not
20 limited to, reviews to determine variances between the
21 quantities of products that a provider had on hand and
22 available to be purveyed to Medicaid recipients during the
23 review period and the quantities of the same products paid for
24 by the Medicaid program for the same period, taking into
25 appropriate consideration sales of the same products to
26 non-Medicaid customers during the same period. In meeting its
27 burden of proof in any administrative or court proceeding, the
28 agency may introduce the results of such statistical methods
29 as evidence of overpayment.
30 (20) When making a determination that an overpayment
31 has occurred, the agency shall prepare and issue an audit
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1 report to the provider showing the calculation of
2 overpayments.
3 (21) The audit report, supported by agency work
4 papers, showing an overpayment to a provider constitutes
5 evidence of the overpayment. A provider may not present or
6 elicit testimony, either on direct examination or
7 cross-examination in any court or administrative proceeding,
8 regarding the purchase or acquisition by any means of drugs,
9 goods, or supplies; sales or divestment by any means of drugs,
10 goods, or supplies; or inventory of drugs, goods, or supplies,
11 unless such acquisition, sales, divestment, or inventory is
12 documented by written invoices, written inventory records, or
13 other competent written documentary evidence maintained in the
14 normal course of the provider's business. Notwithstanding the
15 applicable rules of discovery, all documentation that will be
16 offered as evidence at an administrative hearing on a Medicaid
17 overpayment must be exchanged by all parties at least 14 days
18 before the administrative hearing or must be excluded from
19 consideration.
20 (22)(a) In an audit or investigation of a violation
21 committed by a provider which is conducted pursuant to this
22 section, the agency is entitled to recover all investigative,
23 legal, and expert witness costs if the agency's findings were
24 not contested by the provider or, if contested, the agency
25 ultimately prevailed.
26 (b) The agency has the burden of documenting the
27 costs, which include salaries and employee benefits and
28 out-of-pocket expenses. The amount of costs that may be
29 recovered must be reasonable in relation to the seriousness of
30 the violation and must be set taking into consideration the
31
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1 financial resources, earning ability, and needs of the
2 provider, who has the burden of demonstrating such factors.
3 (c) The provider may pay the costs over a period to be
4 determined by the agency if the agency determines that an
5 extreme hardship would result to the provider from immediate
6 full payment. Any default in payment of costs may be
7 collected by any means authorized by law.
8 (23) If the agency imposes an administrative sanction
9 under this section upon any provider or other person who is
10 regulated by another state entity, the agency shall notify
11 that other entity of the imposition of the sanction. Such
12 notification must include the provider's or person's name and
13 license number and the specific reasons for sanction.
14 (24)(a) The agency may withhold Medicaid payments, in
15 whole or in part, to a provider upon receipt of reliable
16 evidence that the circumstances giving rise to the need for a
17 withholding of payments involve fraud, willful
18 misrepresentation, or abuse under the Medicaid program, or a
19 crime committed while rendering goods or services to Medicaid
20 recipients, pending completion of legal proceedings. If it is
21 determined that fraud, willful misrepresentation, abuse, or a
22 crime did not occur, the payments withheld must be paid to the
23 provider within 14 days after such determination with interest
24 at the rate of 10 percent a year. Any money withheld in
25 accordance with this paragraph shall be placed in a suspended
26 account, readily accessible to the agency, so that any payment
27 ultimately due the provider shall be made within 14 days.
28 (b) Overpayments owed to the agency bear interest at
29 the rate of 10 percent per year from the date of determination
30 of the overpayment by the agency, and payment arrangements
31 must be made at the conclusion of legal proceedings. A
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1 provider who does not enter into or adhere to an agreed-upon
2 repayment schedule may be terminated by the agency for
3 nonpayment or partial payment.
4 (c) The agency, upon entry of a final agency order, a
5 judgment or order of a court of competent jurisdiction, or a
6 stipulation or settlement, may collect the moneys owed by all
7 means allowable by law, including, but not limited to,
8 notifying any fiscal intermediary of Medicare benefits that
9 the state has a superior right of payment. Upon receipt of
10 such written notification, the Medicare fiscal intermediary
11 shall remit to the state the sum claimed.
12 (25) The agency may impose administrative sanctions
13 against a Medicaid recipient, or the agency may seek any other
14 remedy provided by law, including, but not limited to, the
15 remedies provided in s. 812.035, if the agency finds that a
16 recipient has engaged in solicitation in violation of s.
17 409.920 or that the recipient has otherwise abused the
18 Medicaid program.
19 (26) When the Agency for Health Care Administration
20 has made a probable cause determination and alleged that an
21 overpayment to a Medicaid provider has occurred, the agency,
22 after notice to the provider, may:
23 (a) Withhold, and continue to withhold during the
24 pendency of an administrative hearing pursuant to chapter 120,
25 any medical assistance reimbursement payments until such time
26 as the overpayment is recovered, unless within 30 days after
27 receiving notice thereof the provider:
28 1. Makes repayment in full; or
29 2. Establishes a repayment plan that is satisfactory
30 to the Agency for Health Care Administration.
31
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1 (b) Withhold, and continue to withhold during the
2 pendency of an administrative hearing pursuant to chapter 120,
3 medical assistance reimbursement payments if the terms of a
4 repayment plan are not adhered to by the provider.
5
6 If a provider requests an administrative hearing pursuant to
7 chapter 120, such hearing must be conducted within 90 days
8 following receipt by the provider of the final audit report,
9 absent exceptionally good cause shown as determined by the
10 administrative law judge or hearing officer. Upon issuance of
11 a final order, the balance outstanding of the amount
12 determined to constitute the overpayment shall become due. Any
13 withholding of payments by the Agency for Health Care
14 Administration pursuant to this section shall be limited so
15 that the monthly medical assistance payment is not reduced by
16 more than 10 percent.
17 (27) Venue for all Medicaid program integrity
18 overpayment cases shall lie in Leon County, at the discretion
19 of the agency.
20 (28) Notwithstanding other provisions of law, the
21 agency and the Medicaid Fraud Control Unit of the Department
22 of Legal Affairs may review a provider's non-Medicaid-related
23 records in order to determine the total output of a provider's
24 practice to reconcile quantities of goods or services billed
25 to Medicaid against quantities of goods or services used in
26 the provider's total practice.
27 (29) The agency may terminate a provider's
28 participation in the Medicaid program if the provider fails to
29 reimburse an overpayment that has been determined by final
30 order within 35 days after the date of the final order, unless
31 the provider and the agency have entered into a repayment
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1 agreement. If the final order is overturned on appeal, the
2 provider shall be reinstated.
3 (30) If a provider requests an administrative hearing
4 pursuant to chapter 120, such hearing must be conducted within
5 90 days following assignment of an administrative law judge,
6 absent exceptionally good cause shown as determined by the
7 administrative law judge or hearing officer.
8 (31) Upon issuance of a final order, the outstanding
9 balance of the amount determined to constitute the overpayment
10 shall become due. If a provider fails to make payments in
11 full, fails to enter into a satisfactory repayment plan, or
12 fails to comply with the terms of a repayment plan or
13 settlement agreement, the agency may withhold all medical
14 assistance reimbursement payments until the amount due is paid
15 in full.
16 (32) Duly authorized agents and employees of the
17 agency and the Medicaid Fraud Control Unit of the Department
18 of Legal Affairs shall have the power to inspect, at all
19 reasonable hours and upon proper notice, the records of any
20 pharmacy, wholesale establishment, or manufacturer, or any
21 other place in the state in which drugs and medical supplies
22 are manufactured, packed, packaged, made, stored, sold, or
23 kept for sale, for the purpose of verifying the amount of
24 drugs and medical supplies ordered, delivered, or purchased by
25 a provider.
26 Section 20. Subsections (7) and (8) of section
27 409.920, Florida Statutes, are amended to read:
28 409.920 Medicaid provider fraud.--
29 (7) The Attorney General shall conduct a statewide
30 program of Medicaid fraud control. To accomplish this purpose,
31 the Attorney General shall:
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1 (a) Investigate the possible criminal violation of any
2 applicable state law pertaining to fraud in the administration
3 of the Medicaid program, in the provision of medical
4 assistance, or in the activities of providers of health care
5 under the Medicaid program.
6 (b) Investigate the alleged abuse or neglect of
7 patients in health care facilities receiving payments under
8 the Medicaid program, in coordination with the agency.
9 (c) Investigate the alleged misappropriation of
10 patients' private funds in health care facilities receiving
11 payments under the Medicaid program.
12 (d) Refer to the Office of Statewide Prosecution or
13 the appropriate state attorney all violations indicating a
14 substantial potential for criminal prosecution.
15 (e) Refer to the agency all suspected abusive
16 activities not of a criminal or fraudulent nature.
17 (f) 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 (f)(g) Safeguard the privacy rights of all individuals
22 and provide safeguards to prevent the use of patient medical
23 records for any reason beyond the scope of a specific
24 investigation for fraud or abuse, or both, without the
25 patient's written consent.
26 (g) Publicize to state employees and the public the
27 ability of persons to bring suit under the provisions of the
28 Florida False Claims Act and the potential for the persons
29 bringing a civil action under the Florida False Claims Act to
30 obtain a monetary award.
31
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1 (8) In carrying out the duties and responsibilities
2 under this section subsection, the Attorney General may:
3 (a) Enter upon the premises of any health care
4 provider, excluding a physician, participating in the Medicaid
5 program to examine all accounts and records that may, in any
6 manner, be relevant in determining the existence of fraud in
7 the Medicaid program, to investigate alleged abuse or neglect
8 of patients, or to investigate alleged misappropriation of
9 patients' private funds. A participating physician is required
10 to make available any accounts or records that may, in any
11 manner, be relevant in determining the existence of fraud in
12 the Medicaid program. The accounts or records of a
13 non-Medicaid patient may not be reviewed by, or turned over
14 to, the Attorney General without the patient's written
15 consent.
16 (b) Subpoena witnesses or materials, including medical
17 records relating to Medicaid recipients, within or outside the
18 state and, through any duly designated employee, administer
19 oaths and affirmations and collect evidence for possible use
20 in either civil or criminal judicial proceedings.
21 (c) Request and receive the assistance of any state
22 attorney or law enforcement agency in the investigation and
23 prosecution of any violation of this section.
24 (d) Seek any civil remedy provided by law, including,
25 but not limited to, the remedies provided in ss.
26 68.081-68.092, s. 812.035, and this chapter.
27 (e) Refer to the agency for collection each instance
28 of overpayment to a provider of health care under the Medicaid
29 program which is discovered during the course of an
30 investigation.
31
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1 Section 21. Section 624.91, Florida Statutes, is
2 amended to read:
3 624.91 The Florida Healthy Kids Corporation Act.--
4 (1) SHORT TITLE.--This section may be cited as the
5 "William G. 'Doc' Myers Healthy Kids Corporation Act."
6 (2) LEGISLATIVE INTENT.--
7 (a) The Legislature finds that increased access to
8 health care services could improve children's health and
9 reduce the incidence and costs of childhood illness and
10 disabilities among children in this state. Many children do
11 not have comprehensive, affordable health care services
12 available. It is the intent of the Legislature that the
13 Florida Healthy Kids Corporation provide comprehensive health
14 insurance coverage to such children. The corporation is
15 encouraged to cooperate with any existing health service
16 programs funded by the public or the private sector and to
17 work cooperatively with the Florida Partnership for School
18 Readiness.
19 (b) It is the intent of the Legislature that the
20 Florida Healthy Kids Corporation serve as one of several
21 providers of services to children eligible for medical
22 assistance under Title XXI of the Social Security Act.
23 Although the corporation may serve other children, the
24 Legislature intends the primary recipients of services
25 provided through the corporation be school-age children with a
26 family income below 200 percent of the federal poverty level,
27 who do not qualify for Medicaid. It is also the intent of the
28 Legislature that state and local government Florida Healthy
29 Kids funds, to the extent permissible under federal law, be
30 used to continue and expand coverage, within available
31
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1 appropriations, to children not eligible for federal matching
2 funds under Title XXI obtain matching federal dollars.
3 (3) NONENTITLEMENT.--Nothing in this section shall be
4 construed as providing an individual with an entitlement to
5 health care services. No cause of action shall arise against
6 the state, the Florida Healthy Kids Corporation, or a unit of
7 local government for failure to make health services available
8 under this section.
9 (4) CORPORATION AUTHORIZATION, DUTIES, POWERS.--
10 (a) There is created the Florida Healthy Kids
11 Corporation, a not-for-profit corporation which operates on
12 sites designated by the corporation.
13 (b) The Florida Healthy Kids Corporation shall phase
14 in a program to:
15 1. Organize school children groups to facilitate the
16 provision of comprehensive health insurance coverage to
17 children;
18 2. Arrange for the collection of any family, local
19 contributions, or employer payment or premium, in an amount to
20 be determined by the board of directors, to provide for
21 payment of premiums for comprehensive insurance coverage and
22 for the actual or estimated administrative expenses;
23 3. Arrange for the collection of any contributions to
24 provide for payment of premiums for children who are not
25 eligible for medical assistance under Title XXI of the Social
26 Security Act. Each fiscal year, the corporation shall
27 establish a local match policy for the enrollment of
28 non-Title-XXI-eligible children in the Healthy Kids program.
29 By May 1 of each year, the corporation shall provide written
30 notification of the amount to be remitted to the corporation
31 for the following fiscal year under that policy. Local match
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1 sources may include, but are not limited to, funds provided by
2 municipalities, counties, school boards, hospitals, health
3 care providers, charitable organizations, special taxing
4 districts, and private organizations. The minimum local match
5 cash contributions required each fiscal year and local match
6 credits shall be determined by the General Appropriations Act.
7 The corporation shall calculate a county's local match rate
8 based upon that county's percentage of the state's total
9 non-Title-XXI expenditures as reported in the corporation's
10 most recently audited financial statement. In awarding the
11 local match credits, the corporation may consider factors,
12 including, but not limited to, population density, per capita
13 income, existing child-health-related expenditures, and
14 services in awarding the credits;
15 4. Accept supplemental local match contributions that
16 comply with the requirements of Title XXI of the Social
17 Security Act for the purpose of providing additional coverage
18 in contributing counties under Title XXI;
19 5.3. Establish the administrative and accounting
20 procedures for the operation of the corporation;
21 6.4. Establish, with consultation from appropriate
22 professional organizations, standards for preventive health
23 services and providers and comprehensive insurance benefits
24 appropriate to children; provided that such standards for
25 rural areas shall not limit primary care providers to
26 board-certified pediatricians;
27 7.5. Establish eligibility criteria which children
28 must meet in order to participate in the program;
29 8.6. Establish procedures under which providers of
30 local match to, applicants to, and participants in the program
31
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1 may have grievances reviewed by an impartial body and reported
2 to the board of directors of the corporation;
3 9.7. Establish participation criteria and, if
4 appropriate, contract with an authorized insurer, health
5 maintenance organization, or insurance administrator to
6 provide administrative services to the corporation;
7 10.8. Establish enrollment criteria which shall
8 include penalties or waiting periods of not fewer than 60 days
9 for reinstatement of coverage upon voluntary cancellation for
10 nonpayment of family premiums;
11 11.9. If a space is available, establish a special
12 open enrollment period of 30 days' duration for any child who
13 is enrolled in Medicaid or Medikids if such child loses
14 Medicaid or Medikids eligibility and becomes eligible for the
15 Florida Healthy Kids program;
16 12.10. Contract with authorized insurers or any
17 provider of health care services, meeting standards
18 established by the corporation, for the provision of
19 comprehensive insurance coverage to participants. Such
20 standards shall include criteria under which the corporation
21 may contract with more than one provider of health care
22 services in program sites. Health plans shall be selected
23 through a competitive bid process. The selection of health
24 plans shall be based primarily on quality criteria established
25 by the board. The health plan selection criteria and scoring
26 system, and the scoring results, shall be available upon
27 request for inspection after the bids have been awarded;
28 13.11. Develop and implement a plan to publicize the
29 Florida Healthy Kids Corporation, the eligibility requirements
30 of the program, and the procedures for enrollment in the
31
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1 program and to maintain public awareness of the corporation
2 and the program;
3 14.12. Secure staff necessary to properly administer
4 the corporation. Staff costs shall be funded from state and
5 local matching funds and such other private or public funds as
6 become available. The board of directors shall determine the
7 number of staff members necessary to administer the
8 corporation;
9 15.13. As appropriate, enter into contracts with local
10 school boards or other agencies to provide onsite information,
11 enrollment, and other services necessary to the operation of
12 the corporation;
13 16.14. Provide a report on an annual basis to the
14 Governor, Insurance Commissioner, Commissioner of Education,
15 Senate President, Speaker of the House of Representatives, and
16 Minority Leaders of the Senate and the House of
17 Representatives;
18 17.15. Each fiscal year, establish a maximum number of
19 participants by county, on a statewide basis, who may enroll
20 in the program without the benefit of local matching funds.
21 Thereafter, the corporation may establish local matching
22 requirements for supplemental participation in the program.
23 The corporation may vary local matching requirements and
24 enrollment by county depending on factors which may influence
25 the generation of local match, including, but not limited to,
26 population density, per capita income, existing local tax
27 effort, and other factors. The corporation also may accept
28 in-kind match in lieu of cash for the local match requirement
29 to the extent allowed by Title XXI of the Social Security Act;
30 and
31
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1 18.16. Establish eligibility criteria, premium and
2 cost-sharing requirements, and benefit packages which conform
3 to the provisions of the Florida Kidcare program, as created
4 in ss. 409.810-409.820.
5 (c) Coverage under the corporation's program is
6 secondary to any other available private coverage held by the
7 participant child or family member. The corporation may
8 establish procedures for coordinating benefits under this
9 program with benefits under other public and private coverage.
10 (d) The Florida Healthy Kids Corporation shall be a
11 private corporation not for profit, organized pursuant to
12 chapter 617, and shall have all powers necessary to carry out
13 the purposes of this act, including, but not limited to, the
14 power to receive and accept grants, loans, or advances of
15 funds from any public or private agency and to receive and
16 accept from any source contributions of money, property,
17 labor, or any other thing of value, to be held, used, and
18 applied for the purposes of this act.
19 (5) BOARD OF DIRECTORS.--
20 (a) The Florida Healthy Kids Corporation shall operate
21 subject to the supervision and approval of a board of
22 directors chaired by the Insurance Commissioner or her or his
23 designee, and composed of 14 12 other members selected for
24 3-year terms of office as follows:
25 1. One member appointed by the Commissioner of
26 Education from among three persons nominated by the Florida
27 Association of School Administrators;
28 2. One member appointed by the Commissioner of
29 Education from among three persons nominated by the Florida
30 Association of School Boards;
31
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1 3. One member appointed by the Commissioner of
2 Education from the Office of School Health Programs of the
3 Florida Department of Education;
4 4. One member appointed by the Governor from among
5 three members nominated by the Florida Pediatric Society;
6 5. One member, appointed by the Governor, who
7 represents the Children's Medical Services Program;
8 6. One member appointed by the Insurance Commissioner
9 from among three members nominated by the Florida Hospital
10 Association;
11 7. Two members, appointed by the Insurance
12 Commissioner, who are representatives of authorized health
13 care insurers or health maintenance organizations;
14 8. One member, appointed by the Insurance
15 Commissioner, who represents the Institute for Child Health
16 Policy;
17 9. One member, appointed by the Governor, from among
18 three members nominated by the Florida Academy of Family
19 Physicians;
20 10. One member, appointed by the Governor, who
21 represents the Agency for Health Care Administration; and
22 11. The State Health Officer or her or his designee;
23 12. One member, appointed by the Insurance
24 Commissioner from among three members nominated by the Florida
25 Association of Counties, representing rural counties; and
26 13. One member, appointed by the Governor from among
27 three members nominated by the Florida Association of
28 Counties, representing urban counties.
29 (b) A member of the board of directors may be removed
30 by the official who appointed that member. The board shall
31
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1 appoint an executive director, who is responsible for other
2 staff authorized by the board.
3 (c) Board members are entitled to receive, from funds
4 of the corporation, reimbursement for per diem and travel
5 expenses as provided by s. 112.061.
6 (d) There shall be no liability on the part of, and no
7 cause of action shall arise against, any member of the board
8 of directors, or its employees or agents, for any action they
9 take in the performance of their powers and duties under this
10 act.
11 (6) LICENSING NOT REQUIRED; FISCAL OPERATION.--
12 (a) The corporation shall not be deemed an insurer.
13 The officers, directors, and employees of the corporation
14 shall not be deemed to be agents of an insurer. Neither the
15 corporation nor any officer, director, or employee of the
16 corporation is subject to the licensing requirements of the
17 insurance code or the rules of the Department of Insurance.
18 However, any marketing representative utilized and compensated
19 by the corporation must be appointed as a representative of
20 the insurers or health services providers with which the
21 corporation contracts.
22 (b) The board has complete fiscal control over the
23 corporation and is responsible for all corporate operations.
24 (c) The Department of Insurance shall supervise any
25 liquidation or dissolution of the corporation and shall have,
26 with respect to such liquidation or dissolution, all power
27 granted to it pursuant to the insurance code.
28 (7) ACCESS TO RECORDS; CONFIDENTIALITY;
29 PENALTIES.--Notwithstanding any other laws to the contrary,
30 the Florida Healthy Kids Corporation shall have access to the
31 medical records of a student upon receipt of permission from a
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1 parent or guardian of the student. Such medical records may
2 be maintained by state and local agencies. Any identifying
3 information, including medical records and family financial
4 information, obtained by the corporation pursuant to this
5 subsection is confidential and is exempt from the provisions
6 of s. 119.07(1). Neither the corporation nor the staff or
7 agents of the corporation may release, without the written
8 consent of the participant or the parent or guardian of the
9 participant, to any state or federal agency, to any private
10 business or person, or to any other entity, any confidential
11 information received pursuant to this subsection. A violation
12 of this subsection is a misdemeanor of the second degree,
13 punishable as provided in s. 775.082 or s. 775.083.
14 (8) NOTICE OF FAILURE TO MEET LOCAL MATCH.--The
15 corporation shall notify the Senate President, the Speaker of
16 the House of Representatives, the Governor, and the Department
17 of Banking and Finance of any county not meeting its local
18 match requirement.
19 Section 22. Subsection (2) of section 383.19, Florida
20 Statutes, is amended to read:
21 383.19 Standards; funding; ineligibility.--
22 (2) The department shall designate at least one center
23 to serve a geographic area representing each region of the
24 state in which at least 10,000 live births occur per year, but
25 in no case may there be more than 12 11 regional perinatal
26 intensive care centers established unless specifically
27 authorized in the appropriations act or in this subsection.
28 Medicaid reimbursement shall be made for services provided to
29 patients who are Medicaid recipients. Medicaid reimbursement
30 for in-center obstetrical physician services shall be based
31 upon the obstetrical care group payment system. Medicaid
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1 reimbursement for in-center neonatal physician services shall
2 be based upon the neonatal care group payment system. These
3 prospective payment systems, developed by the department, must
4 place patients into homogeneous groups based on clinical
5 factors, severity of illness, and intensity of care.
6 Outpatient obstetrical services and other related services,
7 such as consultations, shall be reimbursed based on the usual
8 Medicaid method of payment for outpatient medical services.
9 Section 23. Subsection (28) of section 393.063,
10 Florida Statutes, is amended to read:
11 393.063 Definitions.--For the purposes of this
12 chapter:
13 (28) "Intermediate care facility for the
14 developmentally disabled" or "ICF/DD" means a
15 state-owned-and-operated residential facility licensed and
16 certified in accordance with state law, and certified by the
17 Federal Government pursuant to the Social Security Act, as a
18 provider of Medicaid services to persons who are
19 developmentally disabled mentally retarded or who have related
20 conditions. The capacity of such a facility shall not be more
21 than 120 clients.
22 Section 24. Section 400.965, Florida Statutes, is
23 amended to read:
24 400.965 Action by agency against licensee; grounds.--
25 (1) Any of the following conditions constitute grounds
26 for action by the agency against a licensee:
27 (a) A misrepresentation of a material fact in the
28 application;
29 (b) The commission of an intentional or negligent act
30 materially affecting the health or safety of residents of the
31 facility;
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1 (c) A violation of any provision of this part or rules
2 adopted under this part; or
3 (d) The commission of any act constituting a ground
4 upon which application for a license may be denied.
5 (2) If the agency has a reasonable belief that any of
6 such conditions exists, it shall:
7 (a) In the case of an applicant for original
8 licensure, deny the application.
9 (b) In the case of an applicant for relicensure or a
10 current licensee, take administrative action as provided in s.
11 400.968 or s. 400.969 or injunctive action as authorized by s.
12 400.963.
13 (c) In the case of a facility operating without a
14 license, take injunctive action as authorized in s. 400.963.
15 Section 25. Subsection (4) of section 400.968, Florida
16 Statutes, is renumbered as section 400.969, Florida Statutes,
17 and amended to read:
18 400.969 Violation of part; penalties.--
19 (1)(4)(a) Except as provided in s. 400.967(3), a
20 violation of any provision of this part section or rules
21 adopted by the agency under this part section is punishable by
22 payment of an administrative or civil penalty not to exceed
23 $5,000.
24 (2)(b) A violation of this part section or of rules
25 adopted under this part section is a misdemeanor of the first
26 degree, punishable as provided in s. 775.082 or s. 775.083.
27 Each day of a continuing violation is a separate offense.
28 Section 26. The Legislature finds that the home and
29 community-based services delivery system for persons with
30 developmental disabilities and the availability of
31 appropriated funds are two of the critical elements in making
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1 services available. Therefore, it is the intent of the
2 Legislature that the Department of Children and Family
3 Services shall develop and implement a comprehensive redesign
4 of the system. The redesign shall include, at a minimum, all
5 actions necessary to achieve an appropriate rate structure,
6 client choice within a specified service package, appropriate
7 assessment strategies, an efficient billing process that
8 contains reconciliation and monitoring components, a redefined
9 role for support coordinators that avoids potential conflicts
10 of interest, and family/client budgets linked to levels of
11 need. Prior to the release of funds in the lump-sum
12 appropriation, the department shall present a plan to the
13 Executive Office of the Governor, the House Fiscal
14 Responsibility Council, and the Senate Appropriations
15 Committee. The plan must result in a full implementation of
16 the redesigned system no later than July 1, 2003. At a
17 minimum, the plan must provide that the portions related to
18 direct provider enrollment and billing will be operational no
19 later than March 31, 2003. The plan must further provide that
20 a more effective needs assessment instrument will be deployed
21 by January 1, 2003, and that all clients will be assessed with
22 this device by June 30, 2003. In no event may the department
23 select an assessment instrument without appropriate evidence
24 that it will be reliable and valid. Once such evidence has
25 been obtained, however, the department shall determine the
26 feasibility of contracting with an external vendor to apply
27 the new assessment device to all clients receiving services
28 through the Medicaid waiver. In lieu of using an external
29 vendor, the department may use support coordinators for the
30 assessments if it develops sufficient safeguards and training
31
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1 to significantly improve the inter-rater reliability of the
2 support coordinators administering the assessment.
3 Section 27. (1) The Agency for Health Care
4 Administration shall conduct a study of health care services
5 provided to children in the state who are medically fragile or
6 dependent on medical technology and conduct a pilot program in
7 Miami-Dade County to provide subacute pediatric transitional
8 care to a maximum of 30 children at any one time. The purposes
9 of the study and the pilot program are to determine ways to
10 permit children who are medically fragile or dependent on
11 medical technology to successfully make a transition from
12 acute care in a health care institution to living with their
13 families when possible, and to provide cost-effective,
14 subacute transitional care services.
15 (2) The agency, in cooperation with the Children's
16 Medical Services Program in the Department of Health, shall
17 conduct a study to identify the total number of children who
18 are medically fragile or dependent on medical technology, from
19 birth through age 21, in the state. By January 1, 2003, the
20 agency must report to the Legislature regarding the children's
21 ages, the locations where the children are served, the types
22 of services received, itemized costs of the services, and the
23 sources of funding that pay for the services, including the
24 proportional share when more than one funding source pays for
25 a service. The study must include information regarding
26 children who are medically fragile or dependent on medical
27 technology who reside in hospitals, nursing homes, and medical
28 foster care, and those who reside with their parents. The
29 study must describe children served in prescribed pediatric
30 extended care centers, including their ages and the services
31 they receive. The report must identify the total services
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1 provided for each child and the method for paying for those
2 services. The report must also identify the number of such
3 children who could, if appropriate transitional services were
4 available, return home or move to a less institutional
5 setting.
6 (3) Within 30 days after the effective date of this
7 act, the agency shall establish minimum staffing standards and
8 quality requirements for a subacute pediatric transitional
9 care center to be operated as a 2-year pilot program in
10 Miami-Dade County. The pilot program must operate under the
11 license of a hospital licensed under chapter 395, Florida
12 Statutes, or a nursing home licensed under chapter 400,
13 Florida Statutes, and shall use existing beds in the hospital
14 or nursing home. A child's placement in the subacute pediatric
15 transitional care center may not exceed 90 days. The center
16 shall arrange for an alternative placement at the end of a
17 child's stay and a transitional plan for children expected to
18 remain in the facility for the maximum allowed stay.
19 (4) Within 60 days after the effective date of this
20 act, the agency must amend the state Medicaid plan or request
21 any federal waivers necessary to implement and fund the pilot
22 program.
23 (5) The subacute pediatric transitional care center
24 must require level 1 background screening as provided in
25 chapter 435, Florida Statutes, for all employees or
26 prospective employees of the center who are expected to, or
27 whose responsibilities may require them to, provide personal
28 care or services to children, have access to children's living
29 areas, or have access to children's funds or personal
30 property.
31
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1 (6) The subacute pediatric transitional care center
2 must have an advisory board. Membership on the advisory board
3 must include, but need not be limited to:
4 (a) A physician and an advanced registered nurse
5 practitioner who is familiar with services for children who
6 are medically fragile or dependent on medical technology.
7 (b) A registered nurse who has experience in the care
8 of children who are medically fragile or dependent on medical
9 technology.
10 (c) A child development specialist who has experience
11 in the care of children who are medically fragile or dependent
12 on medical technology, and their families.
13 (d) A social worker who has experience in the care of
14 children who are medically fragile or dependent on medical
15 technology, and their families.
16 (e) A consumer representative who is a parent or
17 guardian of a child placed in the center.
18 (7) The advisory board shall:
19 (a) Review the policy and procedure components of the
20 center to ensure conformance with applicable standards
21 developed by the agency; and
22 (b) Provide consultation with respect to the
23 operational and programmatic components of the center.
24 (8) The subacute pediatric transitional care center
25 must have written policies and procedures governing the
26 admission, transfer, and discharge of children.
27 (9) The admission of each child to the center must be
28 under the supervision of the center nursing administrator or
29 his or her designee and must be in accordance with the
30 center's policies and procedures. Each Medicaid admission must
31 be approved as appropriate for placement in the facility by
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1 the Children's Medical Services Multidisciplinary Assessment
2 Team of the Department of Health, in conjunction with the
3 agency.
4 (10) Each child admitted to the center shall be
5 admitted upon prescription of the medical director of the
6 center, licensed pursuant to chapter 458 or chapter 459,
7 Florida Statutes, and the child shall remain under the care of
8 the medical director and the advanced registered nurse
9 practitioner for the duration of his or her stay in the
10 center.
11 (11) Each child admitted to the center must meet at
12 least the following criteria:
13 (a) The child must be medically fragile or dependent
14 on medical technology.
15 (b) The child may not, prior to admission, present
16 significant risk of infection to other children or personnel.
17 The medical and nursing directors shall review, on a
18 case-by-case basis, the condition of any child who is
19 suspected of having an infectious disease to determine whether
20 admission is appropriate.
21 (c) The child must be medically stabilized and require
22 skilled nursing care or other interventions.
23 (12) If the child meets the criteria specified in
24 paragraphs (11)(a), (b), and (c), the medical director or
25 nursing director of the center shall implement a preadmission
26 plan that delineates services to be provided and appropriate
27 sources for such services.
28 (a) If the child is hospitalized at the time of
29 referral, preadmission planning must include the participation
30 of the child's parent or guardian and relevant medical,
31 nursing, social services, and developmental staff to ensure
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1 that the hospital's discharge plans will be implemented
2 following the child's placement in the center.
3 (b) A consent form outlining the purpose of the
4 center, family responsibilities, authorized treatment,
5 appropriate release of liability, and emergency disposition
6 plans must be signed by the parent or guardian and witnessed
7 before the child is admitted to the center. The parent or
8 guardian shall be provided a copy of the consent form.
9 (13) By January 1, 2003, the agency shall report to
10 the Legislature concerning the progress of the pilot program.
11 By January 1, 2004, the agency shall submit to the Legislature
12 a report on the success of the pilot program.
13 (14) This section is subject to the availability of
14 funds and subject to any limitations or directions provided
15 for in the General Appropriations Act or chapter 216, Florida
16 Statutes.
17 Section 28. By January 1, 2003, the Agency for Health
18 Care Administration shall make recommendations to the
19 Legislature as to limits in the amount of home office
20 management and administrative fees which should be allowable
21 for reimbursement for Medicaid providers whose rates are set
22 on a cost-reimbursement basis.
23 Section 29. (1) Notwithstanding s. 409.911(3),
24 Florida Statutes, for the state fiscal year 2002-2003 only,
25 the agency shall distribute moneys under the regular
26 disproportionate share program only to hospitals that meet the
27 federal minimum requirements and to public hospitals. Public
28 hospitals are defined as those hospitals identified as
29 government owned or operated in the Financial Hospital Uniform
30 Reporting System (FHURS) data available to the agency as of
31 January 1, 2002. The following methodology shall be used to
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1 distribute disproportionate share dollars to hospitals that
2 meet the federal minimum requirements and to the public
3 hospitals:
4 (a) For hospitals that meet the federal minimum
5 requirements, the following formula shall be used:
6
7 TAA = TA * (1/5.5)
8 DSHP = (HMD/TMSD)*TA
9
10 TAA = total amount available.
11 TA = total appropriation.
12 DSHP = disproportionate share hospital payment.
13 HMD = hospital Medicaid days.
14 TSD = total state Medicaid days.
15
16 (b) The following formulas shall be used to pay
17 disproportionate share dollars to public hospitals:
18 1. For state mental health hospitals:
19
20 DSHP = (HMD/TMD) * TAAMH
21
22 The total amount available for the state mental
23 health hospitals shall be the difference
24 between the federal cap for Institutions for
25 Mental Diseases and the amounts paid under the
26 mental health disproportionate share program.
27 2. For non-state government owned or operated
28 hospitals with 3,200 or more Medicaid days:
29
30 DSHP = [(.85*HCCD/TCCD) + (.15*HMD/TMD)] *
31 TAAPH
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1 TAAPH = TAA - TAAMH
2
3 3. For non-state government owned or operated
4 hospitals with less than 3,200 Medicaid days, a total of
5 $400,000 shall be distributed equally among these hospitals.
6
7 Where:
8
9 TAA = total available appropriation.
10 TAAPH = total amount available for public
11 hospitals.
12 TAAMH = total amount available for mental
13 health hospitals.
14 DSHP = disproportionate share hospital
15 payments.
16 HMD = hospital Medicaid days.
17 TMD = total state Medicaid days for public
18 hospitals.
19 HCCD = hospital charity care dollars.
20 TCCD = total state charity care dollars for
21 public hospitals.
22
23 In computing the above amounts for public hospitals and
24 hospitals that qualify under the federal minimum requirements,
25 the agency shall use the 1997 audited data. In the event there
26 is no 1997 audited data for a hospital, the agency shall use
27 the 1994 audited data.
28 (2) Notwithstanding s. 409.9112, Florida Statutes, for
29 state fiscal year 2002-2003, only disproportionate share
30 payments to regional perinatal intensive care centers shall be
31 distributed in the same proportion as the disproportionate
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1 share payments made to the regional perinatal intensive care
2 centers in the state fiscal year 2001-2002.
3 (3) Notwithstanding s. 409.9117, Florida Statutes, for
4 state fiscal year 2002-2003 only, disproportionate share
5 payments to hospitals that qualify for primary care
6 disproportionate share payments shall be distributed in the
7 same proportion as the primary care disproportionate share
8 payments made to those hospitals in the state fiscal year
9 2001-2002.
10 (4) In the event the Centers for Medicare and Medicaid
11 Services does not approve Florida's inpatient hospital state
12 plan amendment for the public disproportionate share program
13 by November 1, 2002, the agency may make payments to hospitals
14 under the regular disproportionate share program, regional
15 perinatal intensive care centers disproportionate share
16 program, and the primary care disproportionate share program
17 using the same methodologies used in state fiscal year
18 2001-2002.
19 (5) For state fiscal year 2002-2003 only, no
20 disproportionate share payments shall be made to hospitals
21 under the provisions of s. 409.9119, Florida Statutes.
22 (6) This section is repealed on July 1, 2003.
23 Section 30. The Office of Program Policy Analysis and
24 Government Accountability, assisted by the Agency for Health
25 Care Administration, and the Florida Association of Counties,
26 shall perform a study to determine the fair share of the
27 counties' contribution to Medicaid nursing home costs. The
28 Office of Program Policy Analysis and Government
29 Accountability shall submit a report on the study to the
30 President of the Senate and the Speaker of the House of
31 Representatives by January 1, 2003. The report shall set out
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1 no less than two options and shall make a recommendation as to
2 what would be a fair share of the costs for the counties'
3 contribution for fiscal year 2003-2004. The report shall also
4 set out options and make a recommendation to be considered to
5 ensure that the counties pay their fair share in subsequent
6 years. No recommendation shall be less than the counties'
7 current share of 1.5 percent. Each option shall include a
8 detailed explanation of the analysis that led to the
9 conclusion.
10 Section 31. Effective July 1, 2002, section 1 of
11 chapter 2001-377, Laws of Florida, which repealed subsection
12 (11) of section 409.904, Florida Statutes, is repealed.
13 Section 32. If any provision of this act or its
14 application to any person or circumstance is held invalid, the
15 invalidity shall not affect other provisions or applications
16 of the act which can be given effect without the invalid
17 provision or application, and to this end the provisions of
18 this act are declared severable.
19 Section 33. If any law amended by this act was also
20 amended by a law enacted during the 2002 Regular Session of
21 the Legislature, such laws shall be construed to have been
22 enacted during the same session of the Legislature and full
23 effect shall be given to each if possible.
24 Section 34. Except as otherwise provided herein, this
25 act shall take effect upon becoming a law.
26
27 *****************************************
28 HOUSE SUMMARY
29
Revises various provisions relating to operation of the
30 Florida Medicaid program and to powers and duties of the
Agency for Health Care Administration and the Department
31 of Children and Family Services. See bill for details.
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