Senate Bill sb0390e1
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1 A bill to be entitled
2 An act relating to health care; amending s.
3 400.23, F.S.; delaying the effective date of
4 certain requirements concerning hours of direct
5 care per resident for nursing home facilities;
6 amending s. 409.904, F.S.; revising
7 requirements for certain optional payments
8 under the Medicaid program; amending s.
9 409.906, F.S.; deleting provisions authorizing
10 payment for adult dental services; revising
11 requirements for hearing and visual services to
12 limit such services to persons younger than 21
13 years of age; amending s. 409.908, F.S.,
14 relating to reimbursement of Medicaid
15 providers; conforming a cross-reference;
16 amending s. 409.9081, F.S.; providing a
17 copayment under the Medicaid program for
18 certain nonemergency hospital visits; amending
19 s. 409.912, F.S.; authorizing the Agency for
20 Health Care Administration to establish certain
21 protocols for categories of drugs; removing
22 certain requirements for prior authorization
23 for nursing home residents and
24 institutionalized adults; prohibiting
25 value-added rebates to a pharmaceutical
26 manufacturer; deleting provisions authorizing
27 certain benefits in conjunction with
28 supplemental rebates; amending s. 409.9122,
29 F.S.; revising the percentage of Medicaid
30 recipients required to be enrolled in managed
31 care; amending s. 409.915, F.S.; increasing the
1
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1 requirements for county contributions to
2 Medicaid; amending s. 409.815, F.S., relating
3 to benefits coverage; specifying a maximum
4 annual benefit for children's dental services;
5 revising requirements for the Agency for Health
6 Care Administration in distributing moneys
7 under the regular disproportionate share
8 program for the 2003-2004 fiscal year;
9 providing legislative findings; providing a
10 contingency with respect to specified
11 provisions of the act taking effect; providing
12 an effective date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Paragraph (a) of subsection (3) of section
17 400.23, Florida Statutes, is amended to read:
18 400.23 Rules; evaluation and deficiencies; licensure
19 status.--
20 (3)(a) The agency shall adopt rules providing for the
21 minimum staffing requirements for nursing homes. These
22 requirements shall include, for each nursing home facility, a
23 minimum certified nursing assistant staffing of 2.3 hours of
24 direct care per resident per day beginning January 1, 2002,
25 increasing to 2.6 hours of direct care per resident per day
26 beginning January 1, 2003, and increasing to 2.9 hours of
27 direct care per resident per day beginning July January 1,
28 2004. Beginning January 1, 2002, no facility shall staff below
29 one certified nursing assistant per 20 residents, and a
30 minimum licensed nursing staffing of 1.0 hour of direct
31 resident care per resident per day but never below one
2
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1 licensed nurse per 40 residents. Nursing assistants employed
2 under s. 400.211(2) may be included in computing the staffing
3 ratio for certified nursing assistants only if they provide
4 nursing assistance services to residents on a full-time basis.
5 Each nursing home must document compliance with staffing
6 standards as required under this paragraph and post daily the
7 names of staff on duty for the benefit of facility residents
8 and the public. The agency shall recognize the use of licensed
9 nurses for compliance with minimum staffing requirements for
10 certified nursing assistants, provided that the facility
11 otherwise meets the minimum staffing requirements for licensed
12 nurses and that the licensed nurses so recognized are
13 performing the duties of a certified nursing assistant. Unless
14 otherwise approved by the agency, licensed nurses counted
15 towards the minimum staffing requirements for certified
16 nursing assistants must exclusively perform the duties of a
17 certified nursing assistant for the entire shift and shall not
18 also be counted towards the minimum staffing requirements for
19 licensed nurses. If the agency approved a facility's request
20 to use a licensed nurse to perform both licensed nursing and
21 certified nursing assistant duties, the facility must allocate
22 the amount of staff time specifically spent on certified
23 nursing assistant duties for the purpose of documenting
24 compliance with minimum staffing requirements for certified
25 and licensed nursing staff. In no event may the hours of a
26 licensed nurse with dual job responsibilities be counted
27 twice.
28 Section 2. Subsection (2) of section 409.904, Florida
29 Statutes, is amended to read:
30 409.904 Optional payments for eligible persons.--The
31 agency may make payments for medical assistance and related
3
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1 services on behalf of the following persons who are determined
2 to be eligible subject to the income, assets, and categorical
3 eligibility tests set forth in federal and state law. Payment
4 on behalf of these Medicaid eligible persons is subject to the
5 availability of moneys and any limitations established by the
6 General Appropriations Act or chapter 216.
7 (2) A caretaker relative or parent, A pregnant woman,
8 a child under age 19 who would otherwise qualify for Florida
9 Kidcare Medicaid, or a child up to age 21 who would otherwise
10 qualify under s. 409.903(1), a person age 65 or over, or a
11 blind or disabled person, who would otherwise be eligible for
12 Florida Medicaid, except that the income or assets of such
13 family or person exceed established limitations. For a family
14 or person in one of these coverage groups, medical expenses
15 are deductible from income in accordance with federal
16 requirements in order to make a determination of eligibility.
17 Expenses used to meet spend-down liability are not
18 reimbursable by Medicaid. Effective May 1, 2003, when
19 determining the eligibility of a pregnant woman or, a child,
20 or an aged, blind, or disabled individual, $270 shall be
21 deducted from the countable income of the filing unit. When
22 determining the eligibility of the parent or caretaker
23 relative as defined by Title XIX of the Social Security Act,
24 the additional income disregard of $270 does not apply. A
25 family or person eligible under the coverage known as the
26 "medically needy," is eligible to receive the same services as
27 other Medicaid recipients, with the exception of services in
28 skilled nursing facilities and intermediate care facilities
29 for the developmentally disabled.
30 Section 3. Section 409.906, Florida Statutes, is
31 amended to read:
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1 409.906 Optional Medicaid services.--Subject to
2 specific appropriations, the agency may make payments for
3 services which are optional to the state under Title XIX of
4 the Social Security Act and are furnished by Medicaid
5 providers to recipients who are determined to be eligible on
6 the dates on which the services were provided. Any optional
7 service that is provided shall be provided only when medically
8 necessary and in accordance with state and federal law.
9 Optional services rendered by providers in mobile units to
10 Medicaid recipients may be restricted or prohibited by the
11 agency. Nothing in this section shall be construed to prevent
12 or limit the agency from adjusting fees, reimbursement rates,
13 lengths of stay, number of visits, or number of services, or
14 making any other adjustments necessary to comply with the
15 availability of moneys and any limitations or directions
16 provided for in the General Appropriations Act or chapter 216.
17 If necessary to safeguard the state's systems of providing
18 services to elderly and disabled persons and subject to the
19 notice and review provisions of s. 216.177, the Governor may
20 direct the Agency for Health Care Administration to amend the
21 Medicaid state plan to delete the optional Medicaid service
22 known as "Intermediate Care Facilities for the Developmentally
23 Disabled." Optional services may include:
24 (1) ADULT DENTAL SERVICES.--The agency may pay for
25 medically necessary, emergency dental procedures to alleviate
26 pain or infection. Emergency dental care shall be limited to
27 emergency oral examinations, necessary radiographs,
28 extractions, and incision and drainage of abscess, for a
29 recipient who is age 21 or older. However, Medicaid will not
30 provide reimbursement for dental services provided in a mobile
31 dental unit, except for a mobile dental unit:
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1 (a) Owned by, operated by, or having a contractual
2 agreement with the Department of Health and complying with
3 Medicaid's county health department clinic services program
4 specifications as a county health department clinic services
5 provider.
6 (b) Owned by, operated by, or having a contractual
7 arrangement with a federally qualified health center and
8 complying with Medicaid's federally qualified health center
9 specifications as a federally qualified health center
10 provider.
11 (c) Rendering dental services to Medicaid recipients,
12 21 years of age and older, at nursing facilities.
13 (d) Owned by, operated by, or having a contractual
14 agreement with a state-approved dental educational
15 institution.
16 (1)(2) ADULT HEALTH SCREENING SERVICES.--The agency
17 may pay for an annual routine physical examination, conducted
18 by or under the direction of a licensed physician, for a
19 recipient age 21 or older, without regard to medical
20 necessity, in order to detect and prevent disease, disability,
21 or other health condition or its progression.
22 (2)(3) AMBULATORY SURGICAL CENTER SERVICES.--The
23 agency may pay for services provided to a recipient in an
24 ambulatory surgical center licensed under part I of chapter
25 395, by or under the direction of a licensed physician or
26 dentist.
27 (3)(4) BIRTH CENTER SERVICES.--The agency may pay for
28 examinations and delivery, recovery, and newborn assessment,
29 and related services, provided in a licensed birth center
30 staffed with licensed physicians, certified nurse midwives,
31 and midwives licensed in accordance with chapter 467, to a
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1 recipient expected to experience a low-risk pregnancy and
2 delivery.
3 (4)(5) CASE MANAGEMENT SERVICES.--The agency may pay
4 for primary care case management services rendered to a
5 recipient pursuant to a federally approved waiver, and
6 targeted case management services for specific groups of
7 targeted recipients, for which funding has been provided and
8 which are rendered pursuant to federal guidelines. The agency
9 is authorized to limit reimbursement for targeted case
10 management services in order to comply with any limitations or
11 directions provided for in the General Appropriations Act.
12 Notwithstanding s. 216.292, the Department of Children and
13 Family Services may transfer general funds to the Agency for
14 Health Care Administration to fund state match requirements
15 exceeding the amount specified in the General Appropriations
16 Act for targeted case management services.
17 (5)(6) CHILDREN'S DENTAL SERVICES.--The agency may pay
18 for diagnostic, preventive, or corrective procedures,
19 including orthodontia in severe cases, provided to a recipient
20 under age 21, by or under the supervision of a licensed
21 dentist. Services provided under this program include
22 treatment of the teeth and associated structures of the oral
23 cavity, as well as treatment of disease, injury, or impairment
24 that may affect the oral or general health of the individual.
25 However, Medicaid will not provide reimbursement for dental
26 services provided in a mobile dental unit, except for a mobile
27 dental unit:
28 (a) Owned by, operated by, or having a contractual
29 agreement with the Department of Health and complying with
30 Medicaid's county health department clinic services program
31
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1 specifications as a county health department clinic services
2 provider.
3 (b) Owned by, operated by, or having a contractual
4 arrangement with a federally qualified health center and
5 complying with Medicaid's federally qualified health center
6 specifications as a federally qualified health center
7 provider.
8 (c) Rendering dental services to Medicaid recipients,
9 21 years of age and older, at nursing facilities.
10 (d) Owned by, operated by, or having a contractual
11 agreement with a state-approved dental educational
12 institution.
13 (6)(7) CHIROPRACTIC SERVICES.--The agency may pay for
14 manual manipulation of the spine and initial services,
15 screening, and X rays provided to a recipient by a licensed
16 chiropractic physician.
17 (7)(8) COMMUNITY MENTAL HEALTH SERVICES.--
18 (a) The agency may pay for rehabilitative services
19 provided to a recipient by a mental health or substance abuse
20 provider under contract with the agency or the Department of
21 Children and Family Services to provide such services. Those
22 services which are psychiatric in nature shall be rendered or
23 recommended by a psychiatrist, and those services which are
24 medical in nature shall be rendered or recommended by a
25 physician or psychiatrist. The agency must develop a provider
26 enrollment process for community mental health providers which
27 bases provider enrollment on an assessment of service need.
28 The provider enrollment process shall be designed to control
29 costs, prevent fraud and abuse, consider provider expertise
30 and capacity, and assess provider success in managing
31 utilization of care and measuring treatment outcomes.
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1 Providers will be selected through a competitive procurement
2 or selective contracting process. In addition to other
3 community mental health providers, the agency shall consider
4 for enrollment mental health programs licensed under chapter
5 395 and group practices licensed under chapter 458, chapter
6 459, chapter 490, or chapter 491. The agency is also
7 authorized to continue operation of its behavioral health
8 utilization management program and may develop new services if
9 these actions are necessary to ensure savings from the
10 implementation of the utilization management system. The
11 agency shall coordinate the implementation of this enrollment
12 process with the Department of Children and Family Services
13 and the Department of Juvenile Justice. The agency is
14 authorized to utilize diagnostic criteria in setting
15 reimbursement rates, to preauthorize certain high-cost or
16 highly utilized services, to limit or eliminate coverage for
17 certain services, or to make any other adjustments necessary
18 to comply with any limitations or directions provided for in
19 the General Appropriations Act.
20 (b) The agency is authorized to implement
21 reimbursement and use management reforms in order to comply
22 with any limitations or directions in the General
23 Appropriations Act, which may include, but are not limited to:
24 prior authorization of treatment and service plans; prior
25 authorization of services; enhanced use review programs for
26 highly used services; and limits on services for those
27 determined to be abusing their benefit coverages.
28 (8)(9) DIALYSIS FACILITY SERVICES.--Subject to
29 specific appropriations being provided for this purpose, the
30 agency may pay a dialysis facility that is approved as a
31 dialysis facility in accordance with Title XVIII of the Social
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1 Security Act, for dialysis services that are provided to a
2 Medicaid recipient under the direction of a physician licensed
3 to practice medicine or osteopathic medicine in this state,
4 including dialysis services provided in the recipient's home
5 by a hospital-based or freestanding dialysis facility.
6 (9)(10) DURABLE MEDICAL EQUIPMENT.--The agency may
7 authorize and pay for certain durable medical equipment and
8 supplies provided to a Medicaid recipient as medically
9 necessary.
10 (10)(11) HEALTHY START SERVICES.--The agency may pay
11 for a continuum of risk-appropriate medical and psychosocial
12 services for the Healthy Start program in accordance with a
13 federal waiver. The agency may not implement the federal
14 waiver unless the waiver permits the state to limit enrollment
15 or the amount, duration, and scope of services to ensure that
16 expenditures will not exceed funds appropriated by the
17 Legislature or available from local sources. If the Health
18 Care Financing Administration does not approve a federal
19 waiver for Healthy Start services, the agency, in consultation
20 with the Department of Health and the Florida Association of
21 Healthy Start Coalitions, is authorized to establish a
22 Medicaid certified-match program for Healthy Start services.
23 Participation in the Healthy Start certified-match program
24 shall be voluntary, and reimbursement shall be limited to the
25 federal Medicaid share to Medicaid-enrolled Healthy Start
26 coalitions for services provided to Medicaid recipients. The
27 agency shall take no action to implement a certified-match
28 program without ensuring that the amendment and review
29 requirements of ss. 216.177 and 216.181 have been met.
30 (11)(12) CHILDREN'S HEARING SERVICES.--The agency may
31 pay for hearing and related services, including hearing
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1 evaluations, hearing aid devices, dispensing of the hearing
2 aid, and related repairs, if provided to a recipient younger
3 than 21 years of age by a licensed hearing aid specialist,
4 otolaryngologist, otologist, audiologist, or physician.
5 (12)(13) HOME AND COMMUNITY-BASED SERVICES.--The
6 agency may pay for home-based or community-based services that
7 are rendered to a recipient in accordance with a federally
8 approved waiver program. The agency may limit or eliminate
9 coverage for certain Project AIDS Care Waiver services,
10 preauthorize high-cost or highly utilized services, or make
11 any other adjustments necessary to comply with any limitations
12 or directions provided for in the General Appropriations Act.
13 (13)(14) HOSPICE CARE SERVICES.--The agency may pay
14 for all reasonable and necessary services for the palliation
15 or management of a recipient's terminal illness, if the
16 services are provided by a hospice that is licensed under part
17 VI of chapter 400 and meets Medicare certification
18 requirements.
19 (14)(15) INTERMEDIATE CARE FACILITY FOR THE
20 DEVELOPMENTALLY DISABLED SERVICES.--The agency may pay for
21 health-related care and services provided on a 24-hour-a-day
22 basis by a facility licensed and certified as a Medicaid
23 Intermediate Care Facility for the Developmentally Disabled,
24 for a recipient who needs such care because of a developmental
25 disability.
26 (15)(16) INTERMEDIATE CARE SERVICES.--The agency may
27 pay for 24-hour-a-day intermediate care nursing and
28 rehabilitation services rendered to a recipient in a nursing
29 facility licensed under part II of chapter 400, if the
30 services are ordered by and provided under the direction of a
31 physician.
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1 (16)(17) OPTOMETRIC SERVICES.--The agency may pay for
2 services provided to a recipient, including examination,
3 diagnosis, treatment, and management, related to ocular
4 pathology, if the services are provided by a licensed
5 optometrist or physician.
6 (17)(18) PHYSICIAN ASSISTANT SERVICES.--The agency may
7 pay for all services provided to a recipient by a physician
8 assistant licensed under s. 458.347 or s. 459.022.
9 Reimbursement for such services must be not less than 80
10 percent of the reimbursement that would be paid to a physician
11 who provided the same services.
12 (18)(19) PODIATRIC SERVICES.--The agency may pay for
13 services, including diagnosis and medical, surgical,
14 palliative, and mechanical treatment, related to ailments of
15 the human foot and lower leg, if provided to a recipient by a
16 podiatric physician licensed under state law.
17 (19)(20) PRESCRIBED DRUG SERVICES.--The agency may pay
18 for medications that are prescribed for a recipient by a
19 physician or other licensed practitioner of the healing arts
20 authorized to prescribe medications and that are dispensed to
21 the recipient by a licensed pharmacist or physician in
22 accordance with applicable state and federal law.
23 (20)(21) REGISTERED NURSE FIRST ASSISTANT
24 SERVICES.--The agency may pay for all services provided to a
25 recipient by a registered nurse first assistant as described
26 in s. 464.027. Reimbursement for such services may not be
27 less than 80 percent of the reimbursement that would be paid
28 to a physician providing the same services.
29 (21)(22) STATE HOSPITAL SERVICES.--The agency may pay
30 for all-inclusive psychiatric inpatient hospital care provided
31 to a recipient age 65 or older in a state mental hospital.
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1 (22)(23) CHILDREN'S VISUAL SERVICES.--The agency may
2 pay for visual examinations, eyeglasses, and eyeglass repairs
3 for a recipient younger than 21 years of age, if they are
4 prescribed by a licensed physician specializing in diseases of
5 the eye or by a licensed optometrist.
6 (23)(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.--The
7 Agency for Health Care Administration, in consultation with
8 the Department of Children and Family Services, may establish
9 a targeted case-management project in those counties
10 identified by the Department of Children and Family Services
11 and for all counties with a community-based child welfare
12 project, as authorized under s. 409.1671, which have been
13 specifically approved by the department. Results of targeted
14 case management projects shall be reported to the Social
15 Services Estimating Conference established under s. 216.136.
16 The covered group of individuals who are eligible to receive
17 targeted case management include children who are eligible for
18 Medicaid; who are between the ages of birth through 21; and
19 who are under protective supervision or postplacement
20 supervision, under foster-care supervision, or in shelter care
21 or foster care. The number of individuals who are eligible to
22 receive targeted case management shall be limited to the
23 number for whom the Department of Children and Family Services
24 has available matching funds to cover the costs. The general
25 revenue funds required to match the funds for services
26 provided by the community-based child welfare projects are
27 limited to funds available for services described under s.
28 409.1671. The Department of Children and Family Services may
29 transfer the general revenue matching funds as billed by the
30 Agency for Health Care Administration.
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1 (24)(25) ASSISTIVE-CARE SERVICES.--The agency may pay
2 for assistive-care services provided to recipients with
3 functional or cognitive impairments residing in assisted
4 living facilities, adult family-care homes, or residential
5 treatment facilities. These services may include health
6 support, assistance with the activities of daily living and
7 the instrumental acts of daily living, assistance with
8 medication administration, and arrangements for health care.
9 Section 4. Subsection (20) of section 409.908, Florida
10 Statutes, is amended to read:
11 409.908 Reimbursement of Medicaid providers.--Subject
12 to specific appropriations, the agency shall reimburse
13 Medicaid providers, in accordance with state and federal law,
14 according to methodologies set forth in the rules of the
15 agency and in policy manuals and handbooks incorporated by
16 reference therein. These methodologies may include fee
17 schedules, reimbursement methods based on cost reporting,
18 negotiated fees, competitive bidding pursuant to s. 287.057,
19 and other mechanisms the agency considers efficient and
20 effective for purchasing services or goods on behalf of
21 recipients. If a provider is reimbursed based on cost
22 reporting and submits a cost report late and that cost report
23 would have been used to set a lower reimbursement rate for a
24 rate semester, then the provider's rate for that semester
25 shall be retroactively calculated using the new cost report,
26 and full payment at the recalculated rate shall be affected
27 retroactively. Medicare-granted extensions for filing cost
28 reports, if applicable, shall also apply to Medicaid cost
29 reports. Payment for Medicaid compensable services made on
30 behalf of Medicaid eligible persons is subject to the
31 availability of moneys and any limitations or directions
14
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1 provided for in the General Appropriations Act or chapter 216.
2 Further, nothing in this section shall be construed to prevent
3 or limit the agency from adjusting fees, reimbursement rates,
4 lengths of stay, number of visits, or number of services, or
5 making any other adjustments necessary to comply with the
6 availability of moneys and any limitations or directions
7 provided for in the General Appropriations Act, provided the
8 adjustment is consistent with legislative intent.
9 (20) A renal dialysis facility that provides dialysis
10 services under s. 409.906(8) s. 409.906(9) must be reimbursed
11 the lesser of the amount billed by the provider, the
12 provider's usual and customary charge, or the maximum
13 allowable fee established by the agency, whichever amount is
14 less.
15 Section 5. Subsection (1) of section 409.9081, Florida
16 Statutes, is amended to read:
17 409.9081 Copayments.--
18 (1) The agency shall require, subject to federal
19 regulations and limitations, each Medicaid recipient to pay at
20 the time of service a nominal copayment for the following
21 Medicaid services:
22 (a) Hospital outpatient services: up to $3 for each
23 hospital outpatient visit.
24 (b) Physician services: up to $2 copayment for each
25 visit with a physician licensed under chapter 458, chapter
26 459, chapter 460, chapter 461, or chapter 463.
27 (c) Hospital emergency department visits for
28 nonemergency care: $15 for each emergency department visit.
29 Section 6. Section 409.912, Florida Statutes, is
30 amended to read:
31
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1 409.912 Cost-effective purchasing of health care.--The
2 agency shall purchase goods and services for Medicaid
3 recipients in the most cost-effective manner consistent with
4 the delivery of quality medical care. The agency shall
5 maximize the use of prepaid per capita and prepaid aggregate
6 fixed-sum basis services when appropriate and other
7 alternative service delivery and reimbursement methodologies,
8 including competitive bidding pursuant to s. 287.057, designed
9 to facilitate the cost-effective purchase of a case-managed
10 continuum of care. The agency shall also require providers to
11 minimize the exposure of recipients to the need for acute
12 inpatient, custodial, and other institutional care and the
13 inappropriate or unnecessary use of high-cost services. The
14 agency may establish prior authorization requirements for
15 certain populations of Medicaid beneficiaries, certain drug
16 classes, or particular drugs to prevent fraud, abuse, overuse,
17 and possible dangerous drug interactions. The agency may also
18 establish step-therapy protocols for the categories of drugs
19 representing Cox II and proton pump inhibitor drugs. The
20 Pharmaceutical and Therapeutics Committee shall make
21 recommendations to the agency on drugs for which prior
22 authorization is required. The agency shall inform the
23 Pharmaceutical and Therapeutics Committee of its decisions
24 regarding drugs subject to prior authorization.
25 (1) The agency may enter into agreements with
26 appropriate agents of other state agencies or of any agency of
27 the Federal Government and accept such duties in respect to
28 social welfare or public aid as may be necessary to implement
29 the provisions of Title XIX of the Social Security Act and ss.
30 409.901-409.920.
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1 (2) The agency may contract with health maintenance
2 organizations certified pursuant to part I of chapter 641 for
3 the provision of services to recipients.
4 (3) The agency may contract with:
5 (a) An entity that provides no prepaid health care
6 services other than Medicaid services under contract with the
7 agency and which is owned and operated by a county, county
8 health department, or county-owned and operated hospital to
9 provide health care services on a prepaid or fixed-sum basis
10 to recipients, which entity may provide such prepaid services
11 either directly or through arrangements with other providers.
12 Such prepaid health care services entities must be licensed
13 under parts I and III by January 1, 1998, and until then are
14 exempt from the provisions of part I of chapter 641. An entity
15 recognized under this paragraph which demonstrates to the
16 satisfaction of the Department of Insurance that it is backed
17 by the full faith and credit of the county in which it is
18 located may be exempted from s. 641.225.
19 (b) An entity that is providing comprehensive
20 behavioral health care services to certain Medicaid recipients
21 through a capitated, prepaid arrangement pursuant to the
22 federal waiver provided for by s. 409.905(5). Such an entity
23 must be licensed under chapter 624, chapter 636, or chapter
24 641 and must possess the clinical systems and operational
25 competence to manage risk and provide comprehensive behavioral
26 health care to Medicaid recipients. As used in this paragraph,
27 the term "comprehensive behavioral health care services" means
28 covered mental health and substance abuse treatment services
29 that are available to Medicaid recipients. The secretary of
30 the Department of Children and Family Services shall approve
31 provisions of procurements related to children in the
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1 department's care or custody prior to enrolling such children
2 in a prepaid behavioral health plan. Any contract awarded
3 under this paragraph must be competitively procured. In
4 developing the behavioral health care prepaid plan procurement
5 document, the agency shall ensure that the procurement
6 document requires the contractor to develop and implement a
7 plan to ensure compliance with s. 394.4574 related to services
8 provided to residents of licensed assisted living facilities
9 that hold a limited mental health license. The agency must
10 ensure that Medicaid recipients have available the choice of
11 at least two managed care plans for their behavioral health
12 care services. To ensure unimpaired access to behavioral
13 health care services by Medicaid recipients, all contracts
14 issued pursuant to this paragraph shall require 80 percent of
15 the capitation paid to the managed care plan, including health
16 maintenance organizations, to be expended for the provision of
17 behavioral health care services. In the event the managed care
18 plan expends less than 80 percent of the capitation paid
19 pursuant to this paragraph for the provision of behavioral
20 health care services, the difference shall be returned to the
21 agency. The agency shall provide the managed care plan with a
22 certification letter indicating the amount of capitation paid
23 during each calendar year for the provision of behavioral
24 health care services pursuant to this section. The agency may
25 reimburse for substance-abuse-treatment services on a
26 fee-for-service basis until the agency finds that adequate
27 funds are available for capitated, prepaid arrangements.
28 1. By January 1, 2001, the agency shall modify the
29 contracts with the entities providing comprehensive inpatient
30 and outpatient mental health care services to Medicaid
31
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1 recipients in Hillsborough, Highlands, Hardee, Manatee, and
2 Polk Counties, to include substance-abuse-treatment services.
3 2. By December 31, 2001, the agency shall contract
4 with entities providing comprehensive behavioral health care
5 services to Medicaid recipients through capitated, prepaid
6 arrangements in Charlotte, Collier, DeSoto, Escambia, Glades,
7 Hendry, Lee, Okaloosa, Pasco, Pinellas, Santa Rosa, Sarasota,
8 and Walton Counties. The agency may contract with entities
9 providing comprehensive behavioral health care services to
10 Medicaid recipients through capitated, prepaid arrangements in
11 Alachua County. The agency may determine if Sarasota County
12 shall be included as a separate catchment area or included in
13 any other agency geographic area.
14 3. Children residing in a Department of Juvenile
15 Justice residential program approved as a Medicaid behavioral
16 health overlay services provider shall not be included in a
17 behavioral health care prepaid health plan pursuant to this
18 paragraph.
19 4. In converting to a prepaid system of delivery, the
20 agency shall in its procurement document require an entity
21 providing comprehensive behavioral health care services to
22 prevent the displacement of indigent care patients by
23 enrollees in the Medicaid prepaid health plan providing
24 behavioral health care services from facilities receiving
25 state funding to provide indigent behavioral health care, to
26 facilities licensed under chapter 395 which do not receive
27 state funding for indigent behavioral health care, or
28 reimburse the unsubsidized facility for the cost of behavioral
29 health care provided to the displaced indigent care patient.
30 5. Traditional community mental health providers under
31 contract with the Department of Children and Family Services
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1 pursuant to part IV of chapter 394 and inpatient mental health
2 providers licensed pursuant to chapter 395 must be offered an
3 opportunity to accept or decline a contract to participate in
4 any provider network for prepaid behavioral health services.
5 (c) A federally qualified health center or an entity
6 owned by one or more federally qualified health centers or an
7 entity owned by other migrant and community health centers
8 receiving non-Medicaid financial support from the Federal
9 Government to provide health care services on a prepaid or
10 fixed-sum basis to recipients. Such prepaid health care
11 services entity must be licensed under parts I and III of
12 chapter 641, but shall be prohibited from serving Medicaid
13 recipients on a prepaid basis, until such licensure has been
14 obtained. However, such an entity is exempt from s. 641.225
15 if the entity meets the requirements specified in subsections
16 (14) and (15).
17 (d) No more than four provider service networks for
18 demonstration projects to test Medicaid direct contracting.
19 The demonstration projects may be reimbursed on a
20 fee-for-service or prepaid basis. A provider service network
21 which is reimbursed by the agency on a prepaid basis shall be
22 exempt from parts I and III of chapter 641, but must meet
23 appropriate financial reserve, quality assurance, and patient
24 rights requirements as established by the agency. The agency
25 shall award contracts on a competitive bid basis and shall
26 select bidders based upon price and quality of care. Medicaid
27 recipients assigned to a demonstration project shall be chosen
28 equally from those who would otherwise have been assigned to
29 prepaid plans and MediPass. The agency is authorized to seek
30 federal Medicaid waivers as necessary to implement the
31 provisions of this section. A demonstration project awarded
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1 pursuant to this paragraph shall be for 4 years from the date
2 of implementation.
3 (e) An entity that provides comprehensive behavioral
4 health care services to certain Medicaid recipients through an
5 administrative services organization agreement. Such an entity
6 must possess the clinical systems and operational competence
7 to provide comprehensive health care to Medicaid recipients.
8 As used in this paragraph, the term "comprehensive behavioral
9 health care services" means covered mental health and
10 substance abuse treatment services that are available to
11 Medicaid recipients. Any contract awarded under this paragraph
12 must be competitively procured. The agency must ensure that
13 Medicaid recipients have available the choice of at least two
14 managed care plans for their behavioral health care services.
15 (f) An entity that provides in-home physician services
16 to test the cost-effectiveness of enhanced home-based medical
17 care to Medicaid recipients with degenerative neurological
18 diseases and other diseases or disabling conditions associated
19 with high costs to Medicaid. The program shall be designed to
20 serve very disabled persons and to reduce Medicaid reimbursed
21 costs for inpatient, outpatient, and emergency department
22 services. The agency shall contract with vendors on a
23 risk-sharing basis.
24 (g) Children's provider networks that provide care
25 coordination and care management for Medicaid-eligible
26 pediatric patients, primary care, authorization of specialty
27 care, and other urgent and emergency care through organized
28 providers designed to service Medicaid eligibles under age 18
29 and pediatric emergency departments' diversion programs. The
30 networks shall provide after-hour operations, including
31 evening and weekend hours, to promote, when appropriate, the
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1 use of the children's networks rather than hospital emergency
2 departments.
3 (h) An entity authorized in s. 430.205 to contract
4 with the agency and the Department of Elderly Affairs to
5 provide health care and social services on a prepaid or
6 fixed-sum basis to elderly recipients. Such prepaid health
7 care services entities are exempt from the provisions of part
8 I of chapter 641 for the first 3 years of operation. An entity
9 recognized under this paragraph that demonstrates to the
10 satisfaction of the Department of Insurance that it is backed
11 by the full faith and credit of one or more counties in which
12 it operates may be exempted from s. 641.225.
13 (i) A Children's Medical Services network, as defined
14 in s. 391.021.
15 (4) The agency may contract with any public or private
16 entity otherwise authorized by this section on a prepaid or
17 fixed-sum basis for the provision of health care services to
18 recipients. An entity may provide prepaid services to
19 recipients, either directly or through arrangements with other
20 entities, if each entity involved in providing services:
21 (a) Is organized primarily for the purpose of
22 providing health care or other services of the type regularly
23 offered to Medicaid recipients;
24 (b) Ensures that services meet the standards set by
25 the agency for quality, appropriateness, and timeliness;
26 (c) Makes provisions satisfactory to the agency for
27 insolvency protection and ensures that neither enrolled
28 Medicaid recipients nor the agency will be liable for the
29 debts of the entity;
30 (d) Submits to the agency, if a private entity, a
31 financial plan that the agency finds to be fiscally sound and
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1 that provides for working capital in the form of cash or
2 equivalent liquid assets excluding revenues from Medicaid
3 premium payments equal to at least the first 3 months of
4 operating expenses or $200,000, whichever is greater;
5 (e) Furnishes evidence satisfactory to the agency of
6 adequate liability insurance coverage or an adequate plan of
7 self-insurance to respond to claims for injuries arising out
8 of the furnishing of health care;
9 (f) Provides, through contract or otherwise, for
10 periodic review of its medical facilities and services, as
11 required by the agency; and
12 (g) Provides organizational, operational, financial,
13 and other information required by the agency.
14 (5) The agency may contract on a prepaid or fixed-sum
15 basis with any health insurer that:
16 (a) Pays for health care services provided to enrolled
17 Medicaid recipients in exchange for a premium payment paid by
18 the agency;
19 (b) Assumes the underwriting risk; and
20 (c) Is organized and licensed under applicable
21 provisions of the Florida Insurance Code and is currently in
22 good standing with the Department of Insurance.
23 (6) The agency may contract on a prepaid or fixed-sum
24 basis with an exclusive provider organization to provide
25 health care services to Medicaid recipients provided that the
26 exclusive provider organization meets applicable managed care
27 plan requirements in this section, ss. 409.9122, 409.9123,
28 409.9128, and 627.6472, and other applicable provisions of
29 law.
30 (7) The Agency for Health Care Administration may
31 provide cost-effective purchasing of chiropractic services on
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1 a fee-for-service basis to Medicaid recipients through
2 arrangements with a statewide chiropractic preferred provider
3 organization incorporated in this state as a not-for-profit
4 corporation. The agency shall ensure that the benefit limits
5 and prior authorization requirements in the current Medicaid
6 program shall apply to the services provided by the
7 chiropractic preferred provider organization.
8 (8) The agency shall not contract on a prepaid or
9 fixed-sum basis for Medicaid services with an entity which
10 knows or reasonably should know that any officer, director,
11 agent, managing employee, or owner of stock or beneficial
12 interest in excess of 5 percent common or preferred stock, or
13 the entity itself, has been found guilty of, regardless of
14 adjudication, or entered a plea of nolo contendere, or guilty,
15 to:
16 (a) Fraud;
17 (b) Violation of federal or state antitrust statutes,
18 including those proscribing price fixing between competitors
19 and the allocation of customers among competitors;
20 (c) Commission of a felony involving embezzlement,
21 theft, forgery, income tax evasion, bribery, falsification or
22 destruction of records, making false statements, receiving
23 stolen property, making false claims, or obstruction of
24 justice; or
25 (d) Any crime in any jurisdiction which directly
26 relates to the provision of health services on a prepaid or
27 fixed-sum basis.
28 (9) The agency, after notifying the Legislature, may
29 apply for waivers of applicable federal laws and regulations
30 as necessary to implement more appropriate systems of health
31 care for Medicaid recipients and reduce the cost of the
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1 Medicaid program to the state and federal governments and
2 shall implement such programs, after legislative approval,
3 within a reasonable period of time after federal approval.
4 These programs must be designed primarily to reduce the need
5 for inpatient care, custodial care and other long-term or
6 institutional care, and other high-cost services.
7 (a) Prior to seeking legislative approval of such a
8 waiver as authorized by this subsection, the agency shall
9 provide notice and an opportunity for public comment. Notice
10 shall be provided to all persons who have made requests of the
11 agency for advance notice and shall be published in the
12 Florida Administrative Weekly not less than 28 days prior to
13 the intended action.
14 (b) Notwithstanding s. 216.292, funds that are
15 appropriated to the Department of Elderly Affairs for the
16 Assisted Living for the Elderly Medicaid waiver and are not
17 expended shall be transferred to the agency to fund
18 Medicaid-reimbursed nursing home care.
19 (10) The agency shall establish a postpayment
20 utilization control program designed to identify recipients
21 who may inappropriately overuse or underuse Medicaid services
22 and shall provide methods to correct such misuse.
23 (11) The agency shall develop and provide coordinated
24 systems of care for Medicaid recipients and may contract with
25 public or private entities to develop and administer such
26 systems of care among public and private health care providers
27 in a given geographic area.
28 (12) The agency shall operate or contract for the
29 operation of utilization management and incentive systems
30 designed to encourage cost-effective use services.
31
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1 (13)(a) The agency shall operate the Comprehensive
2 Assessment and Review (CARES) nursing facility preadmission
3 screening program to ensure that Medicaid payment for nursing
4 facility care is made only for individuals whose conditions
5 require such care and to ensure that long-term care services
6 are provided in the setting most appropriate to the needs of
7 the person and in the most economical manner possible. The
8 CARES program shall also ensure that individuals participating
9 in Medicaid home and community-based waiver programs meet
10 criteria for those programs, consistent with approved federal
11 waivers.
12 (b) The agency shall operate the CARES program through
13 an interagency agreement with the Department of Elderly
14 Affairs.
15 (c) Prior to making payment for nursing facility
16 services for a Medicaid recipient, the agency must verify that
17 the nursing facility preadmission screening program has
18 determined that the individual requires nursing facility care
19 and that the individual cannot be safely served in
20 community-based programs. The nursing facility preadmission
21 screening program shall refer a Medicaid recipient to a
22 community-based program if the individual could be safely
23 served at a lower cost and the recipient chooses to
24 participate in such program.
25 (d) By January 1 of each year, the agency shall submit
26 a report to the Legislature and the Office of Long-Term-Care
27 Policy describing the operations of the CARES program. The
28 report must describe:
29 1. Rate of diversion to community alternative
30 programs;
31
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1 2. CARES program staffing needs to achieve additional
2 diversions;
3 3. Reasons the program is unable to place individuals
4 in less restrictive settings when such individuals desired
5 such services and could have been served in such settings;
6 4. Barriers to appropriate placement, including
7 barriers due to policies or operations of other agencies or
8 state-funded programs; and
9 5. Statutory changes necessary to ensure that
10 individuals in need of long-term care services receive care in
11 the least restrictive environment.
12 (14)(a) The agency shall identify health care
13 utilization and price patterns within the Medicaid program
14 which are not cost-effective or medically appropriate and
15 assess the effectiveness of new or alternate methods of
16 providing and monitoring service, and may implement such
17 methods as it considers appropriate. Such methods may include
18 disease management initiatives, an integrated and systematic
19 approach for managing the health care needs of recipients who
20 are at risk of or diagnosed with a specific disease by using
21 best practices, prevention strategies, clinical-practice
22 improvement, clinical interventions and protocols, outcomes
23 research, information technology, and other tools and
24 resources to reduce overall costs and improve measurable
25 outcomes.
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. The agency may apply for any federal waivers needed
12 to implement this paragraph.
13 (15) An entity contracting on a prepaid or fixed-sum
14 basis shall, in addition to meeting any applicable statutory
15 surplus requirements, also maintain at all times in the form
16 of cash, investments that mature in less than 180 days
17 allowable as admitted assets by the Department of Insurance,
18 and restricted funds or deposits controlled by the agency or
19 the Department of Insurance, a surplus amount equal to
20 one-and-one-half times the entity's monthly Medicaid prepaid
21 revenues. As used in this subsection, the term "surplus" means
22 the entity's total assets minus total liabilities. If an
23 entity's surplus falls below an amount equal to
24 one-and-one-half times the entity's monthly Medicaid prepaid
25 revenues, the agency shall prohibit the entity from engaging
26 in marketing and preenrollment activities, shall cease to
27 process new enrollments, and shall not renew the entity's
28 contract until the required balance is achieved. The
29 requirements of this subsection do not apply:
30 (a) Where a public entity agrees to fund any deficit
31 incurred by the contracting entity; or
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1 (b) Where the entity's performance and obligations are
2 guaranteed in writing by a guaranteeing organization which:
3 1. Has been in operation for at least 5 years and has
4 assets in excess of $50 million; or
5 2. Submits a written guarantee acceptable to the
6 agency which is irrevocable during the term of the contracting
7 entity's contract with the agency and, upon termination of the
8 contract, until the agency receives proof of satisfaction of
9 all outstanding obligations incurred under the contract.
10 (16)(a) The agency may require an entity contracting
11 on a prepaid or fixed-sum basis to establish a restricted
12 insolvency protection account with a federally guaranteed
13 financial institution licensed to do business in this state.
14 The entity shall deposit into that account 5 percent of the
15 capitation payments made by the agency each month until a
16 maximum total of 2 percent of the total current contract
17 amount is reached. The restricted insolvency protection
18 account may be drawn upon with the authorized signatures of
19 two persons designated by the entity and two representatives
20 of the agency. If the agency finds that the entity is
21 insolvent, the agency may draw upon the account solely with
22 the two authorized signatures of representatives of the
23 agency, and the funds may be disbursed to meet financial
24 obligations incurred by the entity under the prepaid contract.
25 If the contract is terminated, expired, or not continued, the
26 account balance must be released by the agency to the entity
27 upon receipt of proof of satisfaction of all outstanding
28 obligations incurred under this contract.
29 (b) The agency may waive the insolvency protection
30 account requirement in writing when evidence is on file with
31 the agency of adequate insolvency insurance and reinsurance
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1 that will protect enrollees if the entity becomes unable to
2 meet its obligations.
3 (17) An entity that contracts with the agency on a
4 prepaid or fixed-sum basis for the provision of Medicaid
5 services shall reimburse any hospital or physician that is
6 outside the entity's authorized geographic service area as
7 specified in its contract with the agency, and that provides
8 services authorized by the entity to its members, at a rate
9 negotiated with the hospital or physician for the provision of
10 services or according to the lesser of the following:
11 (a) The usual and customary charges made to the
12 general public by the hospital or physician; or
13 (b) The Florida Medicaid reimbursement rate
14 established for the hospital or physician.
15 (18) When a merger or acquisition of a Medicaid
16 prepaid contractor has been approved by the Department of
17 Insurance pursuant to s. 628.4615, the agency shall approve
18 the assignment or transfer of the appropriate Medicaid prepaid
19 contract upon request of the surviving entity of the merger or
20 acquisition if the contractor and the other entity have been
21 in good standing with the agency for the most recent 12-month
22 period, unless the agency determines that the assignment or
23 transfer would be detrimental to the Medicaid recipients or
24 the Medicaid program. To be in good standing, an entity must
25 not have failed accreditation or committed any material
26 violation of the requirements of s. 641.52 and must meet the
27 Medicaid contract requirements. For purposes of this section,
28 a merger or acquisition means a change in controlling interest
29 of an entity, including an asset or stock purchase.
30 (19) Any entity contracting with the agency pursuant
31 to this section to provide health care services to Medicaid
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1 recipients is prohibited from engaging in any of the following
2 practices or activities:
3 (a) Practices that are discriminatory, including, but
4 not limited to, attempts to discourage participation on the
5 basis of actual or perceived health status.
6 (b) Activities that could mislead or confuse
7 recipients, or misrepresent the organization, its marketing
8 representatives, or the agency. Violations of this paragraph
9 include, but are not limited to:
10 1. False or misleading claims that marketing
11 representatives are employees or representatives of the state
12 or county, or of anyone other than the entity or the
13 organization by whom they are reimbursed.
14 2. False or misleading claims that the entity is
15 recommended or endorsed by any state or county agency, or by
16 any other organization which has not certified its endorsement
17 in writing to the entity.
18 3. False or misleading claims that the state or county
19 recommends that a Medicaid recipient enroll with an entity.
20 4. Claims that a Medicaid recipient will lose benefits
21 under the Medicaid program, or any other health or welfare
22 benefits to which the recipient is legally entitled, if the
23 recipient does not enroll with the entity.
24 (c) Granting or offering of any monetary or other
25 valuable consideration for enrollment, except as authorized by
26 subsection (21).
27 (d) Door-to-door solicitation of recipients who have
28 not contacted the entity or who have not invited the entity to
29 make a presentation.
30 (e) Solicitation of Medicaid recipients by marketing
31 representatives stationed in state offices unless approved and
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1 supervised by the agency or its agent and approved by the
2 affected state agency when solicitation occurs in an office of
3 the state agency. The agency shall ensure that marketing
4 representatives stationed in state offices shall market their
5 managed care plans to Medicaid recipients only in designated
6 areas and in such a way as to not interfere with the
7 recipients' activities in the state office.
8 (f) Enrollment of Medicaid recipients.
9 (20) The agency may impose a fine for a violation of
10 this section or the contract with the agency by a person or
11 entity that is under contract with the agency. With respect
12 to any nonwillful violation, such fine shall not exceed $2,500
13 per violation. In no event shall such fine exceed an
14 aggregate amount of $10,000 for all nonwillful violations
15 arising out of the same action. With respect to any knowing
16 and willful violation of this section or the contract with the
17 agency, the agency may impose a fine upon the entity in an
18 amount not to exceed $20,000 for each such violation. In no
19 event shall such fine exceed an aggregate amount of $100,000
20 for all knowing and willful violations arising out of the same
21 action.
22 (21) A health maintenance organization or a person or
23 entity exempt from chapter 641 that is under contract with the
24 agency for the provision of health care services to Medicaid
25 recipients may not use or distribute marketing materials used
26 to solicit Medicaid recipients, unless such materials have
27 been approved by the agency. The provisions of this subsection
28 do not apply to general advertising and marketing materials
29 used by a health maintenance organization to solicit both
30 non-Medicaid subscribers and Medicaid recipients.
31
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1 (22) Upon approval by the agency, health maintenance
2 organizations and persons or entities exempt from chapter 641
3 that are under contract with the agency for the provision of
4 health care services to Medicaid recipients may be permitted
5 within the capitation rate to provide additional health
6 benefits that the agency has found are of high quality, are
7 practicably available, provide reasonable value to the
8 recipient, and are provided at no additional cost to the
9 state.
10 (23) The agency shall utilize the statewide health
11 maintenance organization complaint hotline for the purpose of
12 investigating and resolving Medicaid and prepaid health plan
13 complaints, maintaining a record of complaints and confirmed
14 problems, and receiving disenrollment requests made by
15 recipients.
16 (24) The agency shall require the publication of the
17 health maintenance organization's and the prepaid health
18 plan's consumer services telephone numbers and the "800"
19 telephone number of the statewide health maintenance
20 organization complaint hotline on each Medicaid identification
21 card issued by a health maintenance organization or prepaid
22 health plan contracting with the agency to serve Medicaid
23 recipients and on each subscriber handbook issued to a
24 Medicaid recipient.
25 (25) The agency shall establish a health care quality
26 improvement system for those entities contracting with the
27 agency pursuant to this section, incorporating all the
28 standards and guidelines developed by the Medicaid Bureau of
29 the Health Care Financing Administration as a part of the
30 quality assurance reform initiative. The system shall
31 include, but need not be limited to, the following:
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1 (a) Guidelines for internal quality assurance
2 programs, including standards for:
3 1. Written quality assurance program descriptions.
4 2. Responsibilities of the governing body for
5 monitoring, evaluating, and making improvements to care.
6 3. An active quality assurance committee.
7 4. Quality assurance program supervision.
8 5. Requiring the program to have adequate resources to
9 effectively carry out its specified activities.
10 6. Provider participation in the quality assurance
11 program.
12 7. Delegation of quality assurance program activities.
13 8. Credentialing and recredentialing.
14 9. Enrollee rights and responsibilities.
15 10. Availability and accessibility to services and
16 care.
17 11. Ambulatory care facilities.
18 12. Accessibility and availability of medical records,
19 as well as proper recordkeeping and process for record review.
20 13. Utilization review.
21 14. A continuity of care system.
22 15. Quality assurance program documentation.
23 16. Coordination of quality assurance activity with
24 other management activity.
25 17. Delivering care to pregnant women and infants; to
26 elderly and disabled recipients, especially those who are at
27 risk of institutional placement; to persons with developmental
28 disabilities; and to adults who have chronic, high-cost
29 medical conditions.
30 (b) Guidelines which require the entities to conduct
31 quality-of-care studies which:
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1 1. Target specific conditions and specific health
2 service delivery issues for focused monitoring and evaluation.
3 2. Use clinical care standards or practice guidelines
4 to objectively evaluate the care the entity delivers or fails
5 to deliver for the targeted clinical conditions and health
6 services delivery issues.
7 3. Use quality indicators derived from the clinical
8 care standards or practice guidelines to screen and monitor
9 care and services delivered.
10 (c) Guidelines for external quality review of each
11 contractor which require: focused studies of patterns of care;
12 individual care review in specific situations; and followup
13 activities on previous pattern-of-care study findings and
14 individual-care-review findings. In designing the external
15 quality review function and determining how it is to operate
16 as part of the state's overall quality improvement system, the
17 agency shall construct its external quality review
18 organization and entity contracts to address each of the
19 following:
20 1. Delineating the role of the external quality review
21 organization.
22 2. Length of the external quality review organization
23 contract with the state.
24 3. Participation of the contracting entities in
25 designing external quality review organization review
26 activities.
27 4. Potential variation in the type of clinical
28 conditions and health services delivery issues to be studied
29 at each plan.
30 5. Determining the number of focused pattern-of-care
31 studies to be conducted for each plan.
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1 6. Methods for implementing focused studies.
2 7. Individual care review.
3 8. Followup activities.
4 (26) In order to ensure that children receive health
5 care services for which an entity has already been
6 compensated, an entity contracting with the agency pursuant to
7 this section shall achieve an annual Early and Periodic
8 Screening, Diagnosis, and Treatment (EPSDT) Service screening
9 rate of at least 60 percent for those recipients continuously
10 enrolled for at least 8 months. The agency shall develop a
11 method by which the EPSDT screening rate shall be calculated.
12 For any entity which does not achieve the annual 60 percent
13 rate, the entity must submit a corrective action plan for the
14 agency's approval. If the entity does not meet the standard
15 established in the corrective action plan during the specified
16 timeframe, the agency is authorized to impose appropriate
17 contract sanctions. At least annually, the agency shall
18 publicly release the EPSDT Services screening rates of each
19 entity it has contracted with on a prepaid basis to serve
20 Medicaid recipients.
21 (27) The agency shall perform enrollments and
22 disenrollments for Medicaid recipients who are eligible for
23 MediPass or managed care plans. Notwithstanding the
24 prohibition contained in paragraph (18)(f), managed care plans
25 may perform preenrollments of Medicaid recipients under the
26 supervision of the agency or its agents. For the purposes of
27 this section, "preenrollment" means the provision of marketing
28 and educational materials to a Medicaid recipient and
29 assistance in completing the application forms, but shall not
30 include actual enrollment into a managed care plan. An
31 application for enrollment shall not be deemed complete until
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1 the agency or its agent verifies that the recipient made an
2 informed, voluntary choice. The agency, in cooperation with
3 the Department of Children and Family Services, may test new
4 marketing initiatives to inform Medicaid recipients about
5 their managed care options at selected sites. The agency shall
6 report to the Legislature on the effectiveness of such
7 initiatives. The agency may contract with a third party to
8 perform managed care plan and MediPass enrollment and
9 disenrollment services for Medicaid recipients and is
10 authorized to adopt rules to implement such services. The
11 agency may adjust the capitation rate only to cover the costs
12 of a third-party enrollment and disenrollment contract, and
13 for agency supervision and management of the managed care plan
14 enrollment and disenrollment contract.
15 (28) Any lists of providers made available to Medicaid
16 recipients, MediPass enrollees, or managed care plan enrollees
17 shall be arranged alphabetically showing the provider's name
18 and specialty and, separately, by specialty in alphabetical
19 order.
20 (29) The agency shall establish an enhanced managed
21 care quality assurance oversight function, to include at least
22 the following components:
23 (a) At least quarterly analysis and followup,
24 including sanctions as appropriate, of managed care
25 participant utilization of services.
26 (b) At least quarterly analysis and followup,
27 including sanctions as appropriate, of quality findings of the
28 Medicaid peer review organization and other external quality
29 assurance programs.
30
31
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1 (c) At least quarterly analysis and followup,
2 including sanctions as appropriate, of the fiscal viability of
3 managed care plans.
4 (d) At least quarterly analysis and followup,
5 including sanctions as appropriate, of managed care
6 participant satisfaction and disenrollment surveys.
7 (e) The agency shall conduct regular and ongoing
8 Medicaid recipient satisfaction surveys.
9
10 The analyses and followup activities conducted by the agency
11 under its enhanced managed care quality assurance oversight
12 function shall not duplicate the activities of accreditation
13 reviewers for entities regulated under part III of chapter
14 641, but may include a review of the finding of such
15 reviewers.
16 (30) Each managed care plan that is under contract
17 with the agency to provide health care services to Medicaid
18 recipients shall annually conduct a background check with the
19 Florida Department of Law Enforcement of all persons with
20 ownership interest of 5 percent or more or executive
21 management responsibility for the managed care plan and shall
22 submit to the agency information concerning any such person
23 who has been found guilty of, regardless of adjudication, or
24 has entered a plea of nolo contendere or guilty to, any of the
25 offenses listed in s. 435.03.
26 (31) The agency shall, by rule, develop a process
27 whereby a Medicaid managed care plan enrollee who wishes to
28 enter hospice care may be disenrolled from the managed care
29 plan within 24 hours after contacting the agency regarding
30 such request. The agency rule shall include a methodology for
31 the agency to recoup managed care plan payments on a pro rata
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1 basis if payment has been made for the enrollment month when
2 disenrollment occurs.
3 (32) The agency and entities which contract with the
4 agency to provide health care services to Medicaid recipients
5 under this section or s. 409.9122 must comply with the
6 provisions of s. 641.513 in providing emergency services and
7 care to Medicaid recipients and MediPass recipients.
8 (33) All entities providing health care services to
9 Medicaid recipients shall make available, and encourage all
10 pregnant women and mothers with infants to receive, and
11 provide documentation in the medical records to reflect, the
12 following:
13 (a) Healthy Start prenatal or infant screening.
14 (b) Healthy Start care coordination, when screening or
15 other factors indicate need.
16 (c) Healthy Start enhanced services in accordance with
17 the prenatal or infant screening results.
18 (d) Immunizations in accordance with recommendations
19 of the Advisory Committee on Immunization Practices of the
20 United States Public Health Service and the American Academy
21 of Pediatrics, as appropriate.
22 (e) Counseling and services for family planning to all
23 women and their partners.
24 (f) A scheduled postpartum visit for the purpose of
25 voluntary family planning, to include discussion of all
26 methods of contraception, as appropriate.
27 (g) Referral to the Special Supplemental Nutrition
28 Program for Women, Infants, and Children (WIC).
29 (34) Any entity that provides Medicaid prepaid health
30 plan services shall ensure the appropriate coordination of
31 health care services with an assisted living facility in cases
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1 where a Medicaid recipient is both a member of the entity's
2 prepaid health plan and a resident of the assisted living
3 facility. If the entity is at risk for Medicaid targeted case
4 management and behavioral health services, the entity shall
5 inform the assisted living facility of the procedures to
6 follow should an emergent condition arise.
7 (35) The agency may seek and implement federal waivers
8 necessary to provide for cost-effective purchasing of home
9 health services, private duty nursing services,
10 transportation, independent laboratory services, and durable
11 medical equipment and supplies through competitive bidding
12 pursuant to s. 287.057. The agency may request appropriate
13 waivers from the federal Health Care Financing Administration
14 in order to competitively bid such services. The agency may
15 exclude providers not selected through the bidding process
16 from the Medicaid provider network.
17 (36) The Agency for Health Care Administration is
18 directed to issue a request for proposal or intent to
19 negotiate to implement on a demonstration basis an outpatient
20 specialty services pilot project in a rural and urban county
21 in the state. As used in this subsection, the term
22 "outpatient specialty services" means clinical laboratory,
23 diagnostic imaging, and specified home medical services to
24 include durable medical equipment, prosthetics and orthotics,
25 and infusion therapy.
26 (a) The entity that is awarded the contract to provide
27 Medicaid managed care outpatient specialty services must, at a
28 minimum, meet the following criteria:
29 1. The entity must be licensed by the Department of
30 Insurance under part II of chapter 641.
31
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1 2. The entity must be experienced in providing
2 outpatient specialty services.
3 3. The entity must demonstrate to the satisfaction of
4 the agency that it provides high-quality services to its
5 patients.
6 4. The entity must demonstrate that it has in place a
7 complaints and grievance process to assist Medicaid recipients
8 enrolled in the pilot managed care program to resolve
9 complaints and grievances.
10 (b) The pilot managed care program shall operate for a
11 period of 3 years. The objective of the pilot program shall
12 be to determine the cost-effectiveness and effects on
13 utilization, access, and quality of providing outpatient
14 specialty services to Medicaid recipients on a prepaid,
15 capitated basis.
16 (c) The agency shall conduct a quality assurance
17 review of the prepaid health clinic each year that the
18 demonstration program is in effect. The prepaid health clinic
19 is responsible for all expenses incurred by the agency in
20 conducting a quality assurance review.
21 (d) The entity that is awarded the contract to provide
22 outpatient specialty services to Medicaid recipients shall
23 report data required by the agency in a format specified by
24 the agency, for the purpose of conducting the evaluation
25 required in paragraph (e).
26 (e) The agency shall conduct an evaluation of the
27 pilot managed care program and report its findings to the
28 Governor and the Legislature by no later than January 1, 2001.
29 (37) The agency shall enter into agreements with
30 not-for-profit organizations based in this state for the
31 purpose of providing vision screening.
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1 (38)(a) The agency shall implement a Medicaid
2 prescribed-drug spending-control program that includes the
3 following components:
4 1. Medicaid prescribed-drug coverage for brand-name
5 drugs for adult Medicaid recipients is limited to the
6 dispensing of four brand-name drugs per month per recipient.
7 Children are exempt from this restriction. Antiretroviral
8 agents are excluded from this limitation. No requirements for
9 prior authorization or other restrictions on medications used
10 to treat mental illnesses such as schizophrenia, severe
11 depression, or bipolar disorder may be imposed on Medicaid
12 recipients. Medications that will be available without
13 restriction for persons with mental illnesses include atypical
14 antipsychotic medications, conventional antipsychotic
15 medications, selective serotonin reuptake inhibitors, and
16 other medications used for the treatment of serious mental
17 illnesses. The agency shall also limit the amount of a
18 prescribed drug dispensed to no more than a 34-day supply. The
19 agency shall continue to provide unlimited generic drugs,
20 contraceptive drugs and items, and diabetic supplies. Although
21 a drug may be included on the preferred drug formulary, it
22 would not be exempt from the four-brand limit. The agency may
23 authorize exceptions to the brand-name-drug restriction based
24 upon the treatment needs of the patients, only when such
25 exceptions are based on prior consultation provided by the
26 agency or an agency contractor, but the agency must establish
27 procedures to ensure that:
28 a. There will be a response to a request for prior
29 consultation by telephone or other telecommunication device
30 within 24 hours after receipt of a request for prior
31 consultation;
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1 b. A 72-hour supply of the drug prescribed will be
2 provided in an emergency or when the agency does not provide a
3 response within 24 hours as required by sub-subparagraph a.;
4 and
5 c. Except for the exception for nursing home residents
6 and other institutionalized adults and Except for drugs on the
7 restricted formulary for which prior authorization may be
8 sought by an institutional or community pharmacy, prior
9 authorization for an exception to the brand-name-drug
10 restriction is sought by the prescriber and not by the
11 pharmacy. When prior authorization is granted for a patient in
12 an institutional setting beyond the brand-name-drug
13 restriction, such approval is authorized for 12 months and
14 monthly prior authorization is not required for that patient.
15 2. Reimbursement to pharmacies for Medicaid prescribed
16 drugs shall be set at the average wholesale price less 13.25
17 percent.
18 3. The agency shall develop and implement a process
19 for managing the drug therapies of Medicaid recipients who are
20 using significant numbers of prescribed drugs each month. The
21 management process may include, but is not limited to,
22 comprehensive, physician-directed medical-record reviews,
23 claims analyses, and case evaluations to determine the medical
24 necessity and appropriateness of a patient's treatment plan
25 and drug therapies. The agency may contract with a private
26 organization to provide drug-program-management services. The
27 Medicaid drug benefit management program shall include
28 initiatives to manage drug therapies for HIV/AIDS patients,
29 patients using 20 or more unique prescriptions in a 180-day
30 period, and the top 1,000 patients in annual spending.
31
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1 4. The agency may limit the size of its pharmacy
2 network based on need, competitive bidding, price
3 negotiations, credentialing, or similar criteria. The agency
4 shall give special consideration to rural areas in determining
5 the size and location of pharmacies included in the Medicaid
6 pharmacy network. A pharmacy credentialing process may include
7 criteria such as a pharmacy's full-service status, location,
8 size, patient educational programs, patient consultation,
9 disease-management services, and other characteristics. The
10 agency may impose a moratorium on Medicaid pharmacy enrollment
11 when it is determined that it has a sufficient number of
12 Medicaid-participating providers.
13 5. The agency shall develop and implement a program
14 that requires Medicaid practitioners who prescribe drugs to
15 use a counterfeit-proof prescription pad for Medicaid
16 prescriptions. The agency shall require the use of
17 standardized counterfeit-proof prescription pads by
18 Medicaid-participating prescribers or prescribers who write
19 prescriptions for Medicaid recipients. The agency may
20 implement the program in targeted geographic areas or
21 statewide.
22 6. The agency may enter into arrangements that require
23 manufacturers of generic drugs prescribed to Medicaid
24 recipients to provide rebates of at least 15.1 percent of the
25 average manufacturer price for the manufacturer's generic
26 products. These arrangements shall require that if a
27 generic-drug manufacturer pays federal rebates for
28 Medicaid-reimbursed drugs at a level below 15.1 percent, the
29 manufacturer must provide a supplemental rebate to the state
30 in an amount necessary to achieve a 15.1-percent rebate level.
31
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1 7. The agency may establish a preferred drug formulary
2 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
3 establishment of such formulary, it is authorized to negotiate
4 supplemental rebates from manufacturers that are in addition
5 to those required by Title XIX of the Social Security Act and
6 at no less than 10 percent of the average manufacturer price
7 as defined in 42 U.S.C. s. 1936 on the last day of a quarter
8 unless the federal or supplemental rebate, or both, equals or
9 exceeds 25 percent. There is no upper limit on the
10 supplemental rebates the agency may negotiate. The agency may
11 determine that specific products, brand-name or generic, are
12 competitive at lower rebate percentages. Agreement to pay the
13 minimum supplemental rebate percentage will guarantee a
14 manufacturer that the Medicaid Pharmaceutical and Therapeutics
15 Committee will consider a product for inclusion on the
16 preferred drug formulary. However, a pharmaceutical
17 manufacturer is not guaranteed placement on the formulary by
18 simply paying the minimum supplemental rebate. Agency
19 decisions will be made on the clinical efficacy of a drug and
20 recommendations of the Medicaid Pharmaceutical and
21 Therapeutics Committee, as well as the price of competing
22 products minus federal and state rebates. The agency is
23 authorized to contract with an outside agency or contractor to
24 conduct negotiations for supplemental rebates. For the
25 purposes of this section, the term "supplemental rebates" may
26 include, at the agency's discretion, cash rebates and other
27 program benefits that offset a Medicaid expenditure. Effective
28 July 1, 2003, value-added programs as a substitution for
29 supplemental rebates are prohibited. Such other program
30 benefits may include, but are not limited to, disease
31 management programs, drug product donation programs, drug
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1 utilization control programs, prescriber and beneficiary
2 counseling and education, fraud and abuse initiatives, and
3 other services or administrative investments with guaranteed
4 savings to the Medicaid program in the same year the rebate
5 reduction is included in the General Appropriations Act. The
6 agency is authorized to seek any federal waivers to implement
7 this initiative.
8 8. The agency shall establish an advisory committee
9 for the purposes of studying the feasibility of using a
10 restricted drug formulary for nursing home residents and other
11 institutionalized adults. The committee shall be comprised of
12 seven members appointed by the Secretary of Health Care
13 Administration. The committee members shall include two
14 physicians licensed under chapter 458 or chapter 459; three
15 pharmacists licensed under chapter 465 and appointed from a
16 list of recommendations provided by the Florida Long-Term Care
17 Pharmacy Alliance; and two pharmacists licensed under chapter
18 465.
19 9. The Agency for Health Care Administration shall
20 expand home delivery of pharmacy products. To assist Medicaid
21 patients in securing their prescriptions and reduce program
22 costs, the agency shall expand its current mail-order-pharmacy
23 diabetes-supply program to include all generic and brand-name
24 drugs used by Medicaid patients with diabetes. Medicaid
25 recipients in the current program may obtain nondiabetes drugs
26 on a voluntary basis. This initiative is limited to the
27 geographic area covered by the current contract. The agency
28 may seek and implement any federal waivers necessary to
29 implement this subparagraph.
30 (b) The agency shall implement this subsection to the
31 extent that funds are appropriated to administer the Medicaid
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1 prescribed-drug spending-control program. The agency may
2 contract all or any part of this program to private
3 organizations.
4 (c) The agency shall submit quarterly reports to the
5 Governor, the President of the Senate, and the Speaker of the
6 House of Representatives which must include, but need not be
7 limited to, the progress made in implementing this subsection
8 and its effect on Medicaid prescribed-drug expenditures.
9 (39) Notwithstanding the provisions of chapter 287,
10 the agency may, at its discretion, renew a contract or
11 contracts for fiscal intermediary services one or more times
12 for such periods as the agency may decide; however, all such
13 renewals may not combine to exceed a total period longer than
14 the term of the original contract.
15 (40) The agency shall provide for the development of a
16 demonstration project by establishment in Miami-Dade County of
17 a long-term-care facility licensed pursuant to chapter 395 to
18 improve access to health care for a predominantly minority,
19 medically underserved, and medically complex population and to
20 evaluate alternatives to nursing home care and general acute
21 care for such population. Such project is to be located in a
22 health care condominium and colocated with licensed facilities
23 providing a continuum of care. The establishment of this
24 project is not subject to the provisions of s. 408.036 or s.
25 408.039. The agency shall report its findings to the
26 Governor, the President of the Senate, and the Speaker of the
27 House of Representatives by January 1, 2003.
28 Section 7. Paragraphs (f) and (k) of subsection (2) of
29 section 409.9122, Florida Statutes, are amended to read:
30 409.9122 Mandatory Medicaid managed care enrollment;
31 programs and procedures.--
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1 (2)
2 (f) When a Medicaid recipient does not choose a
3 managed care plan or MediPass provider, the agency shall
4 assign the Medicaid recipient to a managed care plan or
5 MediPass provider. Medicaid recipients who are subject to
6 mandatory assignment but who fail to make a choice shall be
7 assigned to managed care plans until an enrollment of 40 45
8 percent in MediPass and 60 55 percent in managed care plans is
9 achieved. Once this enrollment is achieved, the assignments
10 shall be divided in order to maintain an enrollment in
11 MediPass and managed care plans which is in a 40 45 percent
12 and 60 55 percent proportion, respectively. Thereafter,
13 assignment of Medicaid recipients who fail to make a choice
14 shall be based proportionally on the preferences of recipients
15 who have made a choice in the previous period. Such
16 proportions shall be revised at least quarterly to reflect an
17 update of the preferences of Medicaid recipients. The agency
18 shall disproportionately assign Medicaid-eligible recipients
19 who are required to but have failed to make a choice of
20 managed care plan or MediPass, including children, and who are
21 to be assigned to the MediPass program to children's networks
22 as described in s. 409.912(3)(g), Children's Medical Services
23 network as defined in s. 391.021, exclusive provider
24 organizations, provider service networks, minority physician
25 networks, and pediatric emergency department diversion
26 programs authorized by this chapter or the General
27 Appropriations Act, in such manner as the agency deems
28 appropriate, until the agency has determined that the networks
29 and programs have sufficient numbers to be economically
30 operated. For purposes of this paragraph, when referring to
31 assignment, the term "managed care plans" includes health
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1 maintenance organizations, exclusive provider organizations,
2 provider service networks, minority physician networks,
3 Children's Medical Services network, and pediatric emergency
4 department diversion programs authorized by this chapter or
5 the General Appropriations Act. Beginning July 1, 2002, the
6 agency shall assign all children in families who have not made
7 a choice of a managed care plan or MediPass in the required
8 timeframe to a pediatric emergency room diversion program
9 described in s. 409.912(3)(g) that, as of July 1, 2002, has
10 executed a contract with the agency, until such network or
11 program has reached an enrollment of 15,000 children. Once
12 that minimum enrollment level has been reached, the agency
13 shall assign children who have not chosen a managed care plan
14 or MediPass to the network or program in a manner that
15 maintains the minimum enrollment in the network or program at
16 not less than 15,000 children. To the extent practicable, the
17 agency shall also assign all eligible children in the same
18 family to such network or program. When making assignments,
19 the agency shall take into account the following criteria:
20 1. A managed care plan has sufficient network capacity
21 to meet the need of members.
22 2. The managed care plan or MediPass has previously
23 enrolled the recipient as a member, or one of the managed care
24 plan's primary care providers or MediPass providers has
25 previously provided health care to the recipient.
26 3. The agency has knowledge that the member has
27 previously expressed a preference for a particular managed
28 care plan or MediPass provider as indicated by Medicaid
29 fee-for-service claims data, but has failed to make a choice.
30
31
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1 4. The managed care plan's or MediPass primary care
2 providers are geographically accessible to the recipient's
3 residence.
4 (k) When a Medicaid recipient does not choose a
5 managed care plan or MediPass provider, the agency shall
6 assign the Medicaid recipient to a managed care plan, except
7 in those counties in which there are fewer than two managed
8 care plans accepting Medicaid enrollees, in which case
9 assignment shall be to a managed care plan or a MediPass
10 provider. Medicaid recipients in counties with fewer than two
11 managed care plans accepting Medicaid enrollees who are
12 subject to mandatory assignment but who fail to make a choice
13 shall be assigned to managed care plans until an enrollment of
14 40 45 percent in MediPass and 60 55 percent in managed care
15 plans is achieved. Once that enrollment is achieved, the
16 assignments shall be divided in order to maintain an
17 enrollment in MediPass and managed care plans which is in a 40
18 45 percent and 60 55 percent proportion, respectively. In
19 geographic areas where the agency is contracting for the
20 provision of comprehensive behavioral health services through
21 a capitated prepaid arrangement, recipients who fail to make a
22 choice shall be assigned equally to MediPass or a managed care
23 plan. For purposes of this paragraph, when referring to
24 assignment, the term "managed care plans" includes exclusive
25 provider organizations, provider service networks, Children's
26 Medical Services network, minority physician networks, and
27 pediatric emergency department diversion programs authorized
28 by this chapter or the General Appropriations Act. When making
29 assignments, the agency shall take into account the following
30 criteria:
31
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1 1. A managed care plan has sufficient network capacity
2 to meet the need of members.
3 2. The managed care plan or MediPass has previously
4 enrolled the recipient as a member, or one of the managed care
5 plan's primary care providers or MediPass providers has
6 previously provided health care to the recipient.
7 3. The agency has knowledge that the member has
8 previously expressed a preference for a particular managed
9 care plan or MediPass provider as indicated by Medicaid
10 fee-for-service claims data, but has failed to make a choice.
11 4. The managed care plan's or MediPass primary care
12 providers are geographically accessible to the recipient's
13 residence.
14 5. The agency has authority to make mandatory
15 assignments based on quality of service and performance of
16 managed care plans.
17 Section 8. Subsection (2) of section 409.915, Florida
18 Statutes, is amended to read:
19 409.915 County contributions to Medicaid.--Although
20 the state is responsible for the full portion of the state
21 share of the matching funds required for the Medicaid program,
22 in order to acquire a certain portion of these funds, the
23 state shall charge the counties for certain items of care and
24 service as provided in this section.
25 (2) A county's participation must be 35 percent of the
26 total cost, or the applicable discounted cost paid by the
27 state for Medicaid recipients enrolled in health maintenance
28 organizations or prepaid health plans, of providing the items
29 listed in subsection (1), except that the payments for items
30 listed in paragraph (1)(b) may not exceed $70 $55 per month
31 per person.
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1 Section 9. Paragraph (q) of subsection (2) of section
2 409.815, Florida Statutes, is amended to read:
3 409.815 Health benefits coverage; limitations.--
4 (2) BENCHMARK BENEFITS.--In order for health benefits
5 coverage to qualify for premium assistance payments for an
6 eligible child under ss. 409.810-409.820, the health benefits
7 coverage, except for coverage under Medicaid and Medikids,
8 must include the following minimum benefits, as medically
9 necessary.
10 (q) Dental services.--Subject to a specific
11 appropriation for this benefit, Covered services include those
12 dental services provided to children by the Florida Medicaid
13 program under s. 409.906(5), up to a maximum benefit of $750
14 per enrollee per year.
15 Section 10. (1) Notwithstanding section 409.911(3),
16 Florida Statutes, for the state fiscal year 2003-2004 only,
17 the agency shall distribute moneys under the regular
18 disproportionate share program only to hospitals that meet the
19 federal minimum requirements and to public hospitals. Public
20 hospitals are defined as those hospitals identified as
21 government owned or operated in the Financial Hospital Uniform
22 Reporting System (FHURS) data available to the agency as of
23 January 1, 2002. The following methodology shall be used to
24 distribute disproportionate share dollars to hospitals that
25 meet the federal minimum requirements and to the public
26 hospitals:
27 (a) For hospitals that meet the federal minimum
28 requirements and do not qualify as a public hospital, the
29 following formula shall be used:
30
31 DSHP = (HMD/TMSD)*$1 million
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1
2 DSHP = disproportionate share hospital payment.
3 HMD = hospital Medicaid days.
4 TSD = total state Medicaid days.
5
6 (b) The following formulas shall be used to pay
7 disproportionate share dollars to public hospitals:
8 1. For state mental health hospitals:
9
10 DSHP = (HMD/TMDMH) * TAAMH
11
12 The total amount available for the state mental health
13 hospitals shall be the difference between the federal cap for
14 Institutions for Mental Diseases and the amounts paid under
15 the mental health disproportionate share program.
16 2. For non-state government owned or operated
17 hospitals with 3,200 or more Medicaid days:
18
19 DSHP = [(.82*HCCD/TCCD) + (.18*HMD/TMD)] * TAAPH
20 TAAPH = TAA - TAAMH
21
22 3. For non-state government owned or operated
23 hospitals with less than 3,200 Medicaid days, a total of
24 $400,000 shall be distributed equally among these hospitals.
25
26 Where:
27
28 TAA = total available appropriation.
29 TAAPH = total amount available for public hospitals.
30 TAAMH = total amount available for mental health hospitals.
31 DSHP = disproportionate share hospital payments.
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1 HMD = hospital Medicaid days.
2 TMDMH = total state Medicaid days for mental health days.
3 TMD = total state Medicaid days for public hospitals.
4 HCCD = hospital charity care dollars.
5 TCCD = total state charity care dollars for public non-state
6 hospitals.
7
8 In computing the above amounts for public hospitals and
9 hospitals that qualify under the federal minimum requirements,
10 the agency shall use the 1997 audited data. In the event there
11 is no complete 1997 audited data for a hospital, the agency
12 shall use the 1994 audited data.
13 (2) Notwithstanding section 409.9112, Florida
14 Statutes, for state fiscal year 2003-2004, only
15 disproportionate share payments to regional perinatal
16 intensive care centers shall be distributed in the same
17 proportion as the disproportionate share payments made to the
18 regional perinatal intensive care centers in the state fiscal
19 year 2001-2002.
20 (3) Notwithstanding section 409.9117, Florida
21 Statutes, for state fiscal year 2003-2004 only,
22 disproportionate share payments to hospitals that qualify for
23 primary care disproportionate share payments shall be
24 distributed in the same proportion as the primary care
25 disproportionate share payments made to those hospitals in the
26 state fiscal year 2001-2002.
27 (4) For state fiscal year 2003-2004 only, no
28 disproportionate share payments for specialty hospitals for
29 children shall be made to hospitals under the provisions of
30 section 409.9119, Florida Statutes.
31 (5) This section is repealed on July 1, 2004.
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1 Section 11. The Legislature finds and declares that
2 this act fulfills an important state interest.
3 Section 12. Sections 1, 2, 3, 4, 8, and 11 of this
4 act, and the part of section 6 of this act which amends the
5 introductory portion of section 409.912, Florida Statutes,
6 shall not take effect if one or more bills enacted during the
7 2003 legislative session, or an extension thereof, become law
8 which increase receipts to the General Revenue Fund in an
9 amount sufficient to support contingent appropriations in the
10 2003-2004 General Appropriations Act to:
11 (1) Increase certified nursing assistant staffing to
12 2.9 hours of direct care per resident per day, effective
13 January 1, 2004;
14 (2) Provide Medicaid coverage for adults under the
15 Medically Needy Program;
16 (3) Provide Medicaid coverage for adult emergency
17 dental, visual, and hearing services;
18 (4) Not implement step-therapy protocols for Cox II
19 drugs; and
20 (5) Continue county contributions for Medicaid nursing
21 home care at the current level rather than an increased level.
22 Section 13. Except as otherwise expressly provided in
23 this act, this act shall take effect July 1, 2003.
24
25
26
27
28
29
30
31
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