HB 1349

1	A bill to be entitled
2	An act relating to Medicaid program administration;
3	amending s. 409.907, F.S.; authorizing the Agency for
4	Health Care Administration to revoke or refuse to renew
5	certain provider agreements; amending s. 409.912, F.S.;
6	requiring the agency to maximize the use of risk
7	contracting in providing for health care services;
8	amending s. 409.9122, F.S.; eliminating the proportion
9	restrictions to assigning certain recipients to managed
10	care plans; authorizing the agency to outsource certain
11	Medicaid program administrative functions; requiring the
12	agency to contract with an actuarial firm to conduct an
13	evaluation of certain Medicaid reimbursement
14	methodologies; requiring the agency to report such
15	findings to the Legislature; requiring the agency to
16	conduct a study to design and implement a standard for
17	handling Medicaid records electronically; providing an
18	appropriation; providing an effective date.
19
20	Be It Enacted by the Legislature of the State of Florida:
21
22	Section 1.  Subsection (12) is added to section 409.907,
23	Florida Statutes, to read:
24	409.907  Medicaid provider agreements.--The agency may make
25	payments for medical assistance and related services rendered to
26	Medicaid recipients only to an individual or entity who has a
27	provider agreement in effect with the agency, who is performing
28	services or supplying goods in accordance with federal, state,
29	and local law, and who agrees that no person shall, on the
30	grounds of handicap, race, color, or national origin, or for any
31	other reason, be subjected to discrimination under any program
32	or activity for which the provider receives payment from the
33	agency.
34	(12)  To the extent allowed by federal law, the agency may
35	revoke or refuse to renew a provider agreement if a provider
36	fails to continue meeting the criteria provided under paragraph
37	(9)(b) which would otherwise authorize the agency to deny an
38	application to become a provider.
39	Section 2.  Section 409.912, Florida Statutes, is amended
40	to read:
41	409.912  Cost-effective purchasing of health care.--The
42	agency shall purchase goods and services for Medicaid recipients
43	in the most cost-effective manner consistent with the delivery
44	of quality medical care. The agency shall maximize the use of
45	risk contracting in providing for health care services,
46	including prepaid per capita and prepaid aggregate fixed-sum
47	basis services when appropriate and other alternative service
48	delivery and reimbursement methodologies, including competitive
49	bidding pursuant to s. 287.057, designed to facilitate the cost-
50	effective purchase of a case-managed continuum of care. The
51	agency shall also require providers to minimize the exposure of
52	recipients to the need for acute inpatient, custodial, and other
53	institutional care and the inappropriate or unnecessary use of
54	high-cost services. The agency may establish prior authorization
55	requirements for certain populations of Medicaid beneficiaries,
56	certain drug classes, or particular drugs to prevent fraud,
57	abuse, overuse, and possible dangerous drug interactions. The
58	Pharmaceutical and Therapeutics Committee shall make
59	recommendations to the agency on drugs for which prior
60	authorization is required. The agency shall inform the
61	Pharmaceutical and Therapeutics Committee of its decisions
62	regarding drugs subject to prior authorization.
63	(1)  The agency shall work with the Department of Children
64	and Family Services to ensure access of children and families in
65	the child protection system to needed and appropriate mental
66	health and substance abuse services.
67	(2)  The agency may enter into agreements with appropriate
68	agents of other state agencies or of any agency of the Federal
69	Government and accept such duties in respect to social welfare
70	or public aid as may be necessary to implement the provisions of
71	Title XIX of the Social Security Act and ss. 409.901-409.920.
72	(3)  The agency may contract with health maintenance
73	organizations certified pursuant to part I of chapter 641 for
74	the provision of services to recipients.
75	(4)  The agency may contract with:
76	(a)  An entity that provides no prepaid health care
77	services other than Medicaid services under contract with the
78	agency and which is owned and operated by a county, county
79	health department, or county-owned and operated hospital to
80	provide health care services on a prepaid or fixed-sum basis to
81	recipients, which entity may provide such prepaid services
82	either directly or through arrangements with other providers.
83	Such prepaid health care services entities must be licensed
84	under parts I and III by January 1, 1998, and until then are
85	exempt from the provisions of part I of chapter 641. An entity
86	recognized under this paragraph which demonstrates to the
87	satisfaction of the Office of Insurance Regulation of the
88	Financial Services Commission that it is backed by the full
89	faith and credit of the county in which it is located may be
90	exempted from s. 641.225.
91	(b)  An entity that is providing comprehensive behavioral
92	health care services to certain Medicaid recipients through a
93	capitated, prepaid arrangement pursuant to the federal waiver
94	provided for by s. 409.905(5). Such an entity must be licensed
95	under chapter 624, chapter 636, or chapter 641 and must possess
96	the clinical systems and operational competence to manage risk
97	and provide comprehensive behavioral health care to Medicaid
98	recipients. As used in this paragraph, the term "comprehensive
99	behavioral health care services" means covered mental health and
100	substance abuse treatment services that are available to
101	Medicaid recipients. The secretary of the Department of Children
102	and Family Services shall approve provisions of procurements
103	related to children in the department's care or custody prior to
104	enrolling such children in a prepaid behavioral health plan. Any
105	contract awarded under this paragraph must be competitively
106	procured. In developing the behavioral health care prepaid plan
107	procurement document, the agency shall ensure that the
108	procurement document requires the contractor to develop and
109	implement a plan to ensure compliance with s. 394.4574 related
110	to services provided to residents of licensed assisted living
111	facilities that hold a limited mental health license. The agency
112	shall seek federal approval to contract with a single entity
113	meeting these requirements to provide comprehensive behavioral
114	health care services to all Medicaid recipients in an AHCA area.
115	Each entity must offer sufficient choice of providers in its
116	network to ensure recipient access to care and the opportunity
117	to select a provider with whom they are satisfied. The network
118	shall include all public mental health hospitals. To ensure
119	unimpaired access to behavioral health care services by Medicaid
120	recipients, all contracts issued pursuant to this paragraph
121	shall require 80 percent of the capitation paid to the managed
122	care plan, including health maintenance organizations, to be
123	expended for the provision of behavioral health care services.
124	In the event the managed care plan expends less than 80 percent
125	of the capitation paid pursuant to this paragraph for the
126	provision of behavioral health care services, the difference
127	shall be returned to the agency. The agency shall provide the
128	managed care plan with a certification letter indicating the
129	amount of capitation paid during each calendar year for the
130	provision of behavioral health care services pursuant to this
131	section. The agency may reimburse for substance abuse treatment
132	services on a fee-for-service basis until the agency finds that
133	adequate funds are available for capitated, prepaid
134	arrangements.
135	1.  By January 1, 2001, the agency shall modify the
136	contracts with the entities providing comprehensive inpatient
137	and outpatient mental health care services to Medicaid
138	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
139	Counties, to include substance abuse treatment services.
140	2.  By July 1, 2003, the agency and the Department of
141	Children and Family Services shall execute a written agreement
142	that requires collaboration and joint development of all policy,
143	budgets, procurement documents, contracts, and monitoring plans
144	that have an impact on the state and Medicaid community mental
145	health and targeted case management programs.
146	3.  By July 1, 2006, the agency and the Department of
147	Children and Family Services shall contract with managed care
148	entities in each AHCA area except area 6 or arrange to provide
149	comprehensive inpatient and outpatient mental health and
150	substance abuse services through capitated prepaid arrangements
151	to all Medicaid recipients who are eligible to participate in
152	such plans under federal law and regulation. In AHCA areas where
153	eligible individuals number less than 150,000, the agency shall
154	contract with a single managed care plan. The agency may
155	contract with more than one plan in AHCA areas where the
156	eligible population exceeds 150,000. Contracts awarded pursuant
157	to this section shall be competitively procured. Both for-profit
158	and not-for-profit corporations shall be eligible to compete.
159	4.  By October 1, 2003, the agency and the department shall
160	submit a plan to the Governor, the President of the Senate, and
161	the Speaker of the House of Representatives which provides for
162	the full implementation of capitated prepaid behavioral health
163	care in all areas of the state. The plan shall include
164	provisions which ensure that children and families receiving
165	foster care and other related services are appropriately served
166	and that these services assist the community-based care lead
167	agencies in meeting the goals and outcomes of the child welfare
168	system. The plan will be developed with the participation of
169	community-based lead agencies, community alliances, sheriffs,
170	and community providers serving dependent children.
171	a.  Implementation shall begin in 2003 in those AHCA areas
172	of the state where the agency is able to establish sufficient
173	capitation rates.
174	b.  If the agency determines that the proposed capitation
175	rate in any area is insufficient to provide appropriate
176	services, the agency may adjust the capitation rate to ensure
177	that care will be available. The agency and the department may
178	use existing general revenue to address any additional required
179	match but may not over-obligate existing funds on an annualized
180	basis.
181	c.  Subject to any limitations provided for in the General
182	Appropriations Act, the agency, in compliance with appropriate
183	federal authorization, shall develop policies and procedures
184	that allow for certification of local and state funds.
185	5.  Children residing in a statewide inpatient psychiatric
186	program, or in a Department of Juvenile Justice or a Department
187	of Children and Family Services residential program approved as
188	a Medicaid behavioral health overlay services provider shall not
189	be included in a behavioral health care prepaid health plan
190	pursuant to this paragraph.
191	6.  In converting to a prepaid system of delivery, the
192	agency shall in its procurement document require an entity
193	providing comprehensive behavioral health care services to
194	prevent the displacement of indigent care patients by enrollees
195	in the Medicaid prepaid health plan providing behavioral health
196	care services from facilities receiving state funding to provide
197	indigent behavioral health care, to facilities licensed under
198	chapter 395 which do not receive state funding for indigent
199	behavioral health care, or reimburse the unsubsidized facility
200	for the cost of behavioral health care provided to the displaced
201	indigent care patient.
202	7.  Traditional community mental health providers under
203	contract with the Department of Children and Family Services
204	pursuant to part IV of chapter 394, child welfare providers
205	under contract with the Department of Children and Family
206	Services, and inpatient mental health providers licensed
207	pursuant to chapter 395 must be offered an opportunity to accept
208	or decline a contract to participate in any provider network for
209	prepaid behavioral health services.
210	(c)  A federally qualified health center or an entity owned
211	by one or more federally qualified health centers or an entity
212	owned by other migrant and community health centers receiving
213	non-Medicaid financial support from the Federal Government to
214	provide health care services on a prepaid or fixed-sum basis to
215	recipients. Such prepaid health care services entity must be
216	licensed under parts I and III of chapter 641, but shall be
217	prohibited from serving Medicaid recipients on a prepaid basis,
218	until such licensure has been obtained. However, such an entity
219	is exempt from s. 641.225 if the entity meets the requirements
220	specified in subsections (15) and (16).
221	(d)  A provider service network may be reimbursed on a fee-
222	for-service or prepaid basis. A provider service network which
223	is reimbursed by the agency on a prepaid basis shall be exempt
224	from parts I and III of chapter 641, but must meet appropriate
225	financial reserve, quality assurance, and patient rights
226	requirements as established by the agency. The agency shall
227	award contracts on a competitive bid basis and shall select
228	bidders based upon price and quality of care. Medicaid
229	recipients assigned to a demonstration project shall be chosen
230	equally from those who would otherwise have been assigned to
231	prepaid plans and MediPass. The agency is authorized to seek
232	federal Medicaid waivers as necessary to implement the
233	provisions of this section.
234	(e)  An entity that provides comprehensive behavioral
235	health care services to certain Medicaid recipients through an
236	administrative services organization agreement. Such an entity
237	must possess the clinical systems and operational competence to
238	provide comprehensive health care to Medicaid recipients. As
239	used in this paragraph, the term "comprehensive behavioral
240	health care services" means covered mental health and substance
241	abuse treatment services that are available to Medicaid
242	recipients. Any contract awarded under this paragraph must be
243	competitively procured. The agency must ensure that Medicaid
244	recipients have available the choice of at least two managed
245	care plans for their behavioral health care services.
246	(f)  An entity that provides in-home physician services to
247	test the cost-effectiveness of enhanced home-based medical care
248	to Medicaid recipients with degenerative neurological diseases
249	and other diseases or disabling conditions associated with high
250	costs to Medicaid. The program shall be designed to serve very
251	disabled persons and to reduce Medicaid reimbursed costs for
252	inpatient, outpatient, and emergency department services. The
253	agency shall contract with vendors on a risk-sharing basis.
254	(g)  Children's provider networks that provide care
255	coordination and care management for Medicaid-eligible pediatric
256	patients, primary care, authorization of specialty care, and
257	other urgent and emergency care through organized providers
258	designed to service Medicaid eligibles under age 18 and
259	pediatric emergency departments' diversion programs. The
260	networks shall provide after-hour operations, including evening
261	and weekend hours, to promote, when appropriate, the use of the
262	children's networks rather than hospital emergency departments.
263	(h)  An entity authorized in s. 430.205 to contract with
264	the agency and the Department of Elderly Affairs to provide
265	health care and social services on a prepaid or fixed-sum basis
266	to elderly recipients. Such prepaid health care services
267	entities are exempt from the provisions of part I of chapter 641
268	for the first 3 years of operation. An entity recognized under
269	this paragraph that demonstrates to the satisfaction of the
270	Office of Insurance Regulation that it is backed by the full
271	faith and credit of one or more counties in which it operates
272	may be exempted from s. 641.225.
273	(i)  A Children's Medical Services network, as defined in
274	s. 391.021.
275	(5)  By October 1, 2003, the agency and the department
276	shall, to the extent feasible, develop a plan for implementing
277	new Medicaid procedure codes for emergency and crisis care,
278	supportive residential services, and other services designed to
279	maximize the use of Medicaid funds for Medicaid-eligible
280	recipients. The agency shall include in the agreement developed
281	pursuant to subsection (4) a provision that ensures that the
282	match requirements for these new procedure codes are met by
283	certifying eligible general revenue or local funds that are
284	currently expended on these services by the department with
285	contracted alcohol, drug abuse, and mental health providers. The
286	plan must describe specific procedure codes to be implemented, a
287	projection of the number of procedures to be delivered during
288	fiscal year 2003-2004, and a financial analysis that describes
289	the certified match procedures, and accountability mechanisms,
290	projects the earnings associated with these procedures, and
291	describes the sources of state match. This plan may not be
292	implemented in any part until approved by the Legislative Budget
293	Commission. If such approval has not occurred by December 31,
294	2003, the plan shall be submitted for consideration by the 2004
295	Legislature.
296	(6)  The agency may contract with any public or private
297	entity otherwise authorized by this section on a prepaid or
298	fixed-sum basis for the provision of health care services to
299	recipients. An entity may provide prepaid services to
300	recipients, either directly or through arrangements with other
301	entities, if each entity involved in providing services:
302	(a)  Is organized primarily for the purpose of providing
303	health care or other services of the type regularly offered to
304	Medicaid recipients;
305	(b)  Ensures that services meet the standards set by the
306	agency for quality, appropriateness, and timeliness;
307	(c)  Makes provisions satisfactory to the agency for
308	insolvency protection and ensures that neither enrolled Medicaid
309	recipients nor the agency will be liable for the debts of the
310	entity;
311	(d)  Submits to the agency, if a private entity, a
312	financial plan that the agency finds to be fiscally sound and
313	that provides for working capital in the form of cash or
314	equivalent liquid assets excluding revenues from Medicaid
315	premium payments equal to at least the first 3 months of
316	operating expenses or $200,000, whichever is greater;
317	(e)  Furnishes evidence satisfactory to the agency of
318	adequate liability insurance coverage or an adequate plan of
319	self-insurance to respond to claims for injuries arising out of
320	the furnishing of health care;
321	(f)  Provides, through contract or otherwise, for periodic
322	review of its medical facilities and services, as required by
323	the agency; and
324	(g)  Provides organizational, operational, financial, and
325	other information required by the agency.
326	(7)  The agency may contract on a prepaid or fixed-sum
327	basis with any health insurer that:
328	(a)  Pays for health care services provided to enrolled
329	Medicaid recipients in exchange for a premium payment paid by
330	the agency;
331	(b)  Assumes the underwriting risk; and
332	(c)  Is organized and licensed under applicable provisions
333	of the Florida Insurance Code and is currently in good standing
334	with the Office of Insurance Regulation.
335	(8)  The agency may contract on a prepaid or fixed-sum
336	basis with an exclusive provider organization to provide health
337	care services to Medicaid recipients provided that the exclusive
338	provider organization meets applicable managed care plan
339	requirements in this section, ss. 409.9122, 409.9123, 409.9128,
340	and 627.6472, and other applicable provisions of law.
341	(9)  The Agency for Health Care Administration may provide
342	cost-effective purchasing of chiropractic services on a fee-for-
343	service basis to Medicaid recipients through arrangements with a
344	statewide chiropractic preferred provider organization
345	incorporated in this state as a not-for-profit corporation. The
346	agency shall ensure that the benefit limits and prior
347	authorization requirements in the current Medicaid program shall
348	apply to the services provided by the chiropractic preferred
349	provider organization.
350	(10)  The agency shall not contract on a prepaid or fixed-
351	sum basis for Medicaid services with an entity which knows or
352	reasonably should know that any officer, director, agent,
353	managing employee, or owner of stock or beneficial interest in
354	excess of 5 percent common or preferred stock, or the entity
355	itself, has been found guilty of, regardless of adjudication, or
356	entered a plea of nolo contendere, or guilty, to:
357	(a)  Fraud;
358	(b)  Violation of federal or state antitrust statutes,
359	including those proscribing price fixing between competitors and
360	the allocation of customers among competitors;
361	(c)  Commission of a felony involving embezzlement, theft,
362	forgery, income tax evasion, bribery, falsification or
363	destruction of records, making false statements, receiving
364	stolen property, making false claims, or obstruction of justice;
365	or
366	(d)  Any crime in any jurisdiction which directly relates
367	to the provision of health services on a prepaid or fixed-sum
368	basis.
369	(11)  The agency, after notifying the Legislature, may
370	apply for waivers of applicable federal laws and regulations as
371	necessary to implement more appropriate systems of health care
372	for Medicaid recipients and reduce the cost of the Medicaid
373	program to the state and federal governments and shall implement
374	such programs, after legislative approval, within a reasonable
375	period of time after federal approval. These programs must be
376	designed primarily to reduce the need for inpatient care,
377	custodial care and other long-term or institutional care, and
378	other high-cost services.
379	(a)  Prior to seeking legislative approval of such a waiver
380	as authorized by this subsection, the agency shall provide
381	notice and an opportunity for public comment. Notice shall be
382	provided to all persons who have made requests of the agency for
383	advance notice and shall be published in the Florida
384	Administrative Weekly not less than 28 days prior to the
385	intended action.
386	(b)  Notwithstanding s. 216.292, funds that are
387	appropriated to the Department of Elderly Affairs for the
388	Assisted Living for the Elderly Medicaid waiver and are not
389	expended shall be transferred to the agency to fund Medicaid-
390	reimbursed nursing home care.
391	(12)  The agency shall establish a postpayment utilization
392	control program designed to identify recipients who may
393	inappropriately overuse or underuse Medicaid services and shall
394	provide methods to correct such misuse.
395	(13)  The agency shall develop and provide coordinated
396	systems of care for Medicaid recipients and may contract with
397	public or private entities to develop and administer such
398	systems of care among public and private health care providers
399	in a given geographic area.
400	(14)  The agency shall operate or contract for the
401	operation of utilization management and incentive systems
402	designed to encourage cost-effective use services.
403	(15)(a)  The agency shall operate the Comprehensive
404	Assessment and Review (CARES) nursing facility preadmission
405	screening program to ensure that Medicaid payment for nursing
406	facility care is made only for individuals whose conditions
407	require such care and to ensure that long-term care services are
408	provided in the setting most appropriate to the needs of the
409	person and in the most economical manner possible. The CARES
410	program shall also ensure that individuals participating in
411	Medicaid home and community-based waiver programs meet criteria
412	for those programs, consistent with approved federal waivers.
413	(b)  The agency shall operate the CARES program through an
414	interagency agreement with the Department of Elderly Affairs.
415	(c)  Prior to making payment for nursing facility services
416	for a Medicaid recipient, the agency must verify that the
417	nursing facility preadmission screening program has determined
418	that the individual requires nursing facility care and that the
419	individual cannot be safely served in community-based programs.
420	The nursing facility preadmission screening program shall refer
421	a Medicaid recipient to a community-based program if the
422	individual could be safely served at a lower cost and the
423	recipient chooses to participate in such program.
424	(d)  By January 1 of each year, the agency shall submit a
425	report to the Legislature and the Office of Long-Term-Care
426	Policy describing the operations of the CARES program. The
427	report must describe:
428	1.  Rate of diversion to community alternative programs;
429	2.  CARES program staffing needs to achieve additional
430	diversions;
431	3.  Reasons the program is unable to place individuals in
432	less restrictive settings when such individuals desired such
433	services and could have been served in such settings;
434	4.  Barriers to appropriate placement, including barriers
435	due to policies or operations of other agencies or state-funded
436	programs; and
437	5.  Statutory changes necessary to ensure that individuals
438	in need of long-term care services receive care in the least
439	restrictive environment.
440	(16)(a)  The agency shall identify health care utilization
441	and price patterns within the Medicaid program which are not
442	cost-effective or medically appropriate and assess the
443	effectiveness of new or alternate methods of providing and
444	monitoring service, and may implement such methods as it
445	considers appropriate. Such methods may include disease
446	management initiatives, an integrated and systematic approach
447	for managing the health care needs of recipients who are at risk
448	of or diagnosed with a specific disease by using best practices,
449	prevention strategies, clinical-practice improvement, clinical
450	interventions and protocols, outcomes research, information
451	technology, and other tools and resources to reduce overall
452	costs and improve measurable outcomes.
453	(b)  The responsibility of the agency under this subsection
454	shall include the development of capabilities to identify actual
455	and optimal practice patterns; patient and provider educational
456	initiatives; methods for determining patient compliance with
457	prescribed treatments; fraud, waste, and abuse prevention and
458	detection programs; and beneficiary case management programs.
459	1.  The practice pattern identification program shall
460	evaluate practitioner prescribing patterns based on national and
461	regional practice guidelines, comparing practitioners to their
462	peer groups. The agency and its Drug Utilization Review Board
463	shall consult with a panel of practicing health care
464	professionals consisting of the following: the Speaker of the
465	House of Representatives and the President of the Senate shall
466	each appoint three physicians licensed under chapter 458 or
467	chapter 459; and the Governor shall appoint two pharmacists
468	licensed under chapter 465 and one dentist licensed under
469	chapter 466 who is an oral surgeon. Terms of the panel members
470	shall expire at the discretion of the appointing official. The
471	panel shall begin its work by August 1, 1999, regardless of the
472	number of appointments made by that date. The advisory panel
473	shall be responsible for evaluating treatment guidelines and
474	recommending ways to incorporate their use in the practice
475	pattern identification program. Practitioners who are
476	prescribing inappropriately or inefficiently, as determined by
477	the agency, may have their prescribing of certain drugs subject
478	to prior authorization.
479	2.  The agency shall also develop educational interventions
480	designed to promote the proper use of medications by providers
481	and beneficiaries.
482	3.  The agency shall implement a pharmacy fraud, waste, and
483	abuse initiative that may include a surety bond or letter of
484	credit requirement for participating pharmacies, enhanced
485	provider auditing practices, the use of additional fraud and
486	abuse software, recipient management programs for beneficiaries
487	inappropriately using their benefits, and other steps that will
488	eliminate provider and recipient fraud, waste, and abuse. The
489	initiative shall address enforcement efforts to reduce the
490	number and use of counterfeit prescriptions.
491	4.  By September 30, 2002, the agency shall contract with
492	an entity in the state to implement a wireless handheld clinical
493	pharmacology drug information database for practitioners. The
494	initiative shall be designed to enhance the agency's efforts to
495	reduce fraud, abuse, and errors in the prescription drug benefit
496	program and to otherwise further the intent of this paragraph.
497	5.  The agency may apply for any federal waivers needed to
498	implement this paragraph.
499	(17)  An entity contracting on a prepaid or fixed-sum basis
500	shall, in addition to meeting any applicable statutory surplus
501	requirements, also maintain at all times in the form of cash,
502	investments that mature in less than 180 days allowable as
503	admitted assets by the Office of Insurance Regulation, and
504	restricted funds or deposits controlled by the agency or the
505	Office of Insurance Regulation, a surplus amount equal to one-
506	and-one-half times the entity's monthly Medicaid prepaid
507	revenues. As used in this subsection, the term "surplus" means
508	the entity's total assets minus total liabilities. If an
509	entity's surplus falls below an amount equal to one-and-one-half
510	times the entity's monthly Medicaid prepaid revenues, the agency
511	shall prohibit the entity from engaging in marketing and
512	preenrollment activities, shall cease to process new
513	enrollments, and shall not renew the entity's contract until the
514	required balance is achieved. The requirements of this
515	subsection do not apply:
516	(a)  Where a public entity agrees to fund any deficit
517	incurred by the contracting entity; or
518	(b)  Where the entity's performance and obligations are
519	guaranteed in writing by a guaranteeing organization which:
520	1.  Has been in operation for at least 5 years and has
521	assets in excess of $50 million; or
522	2.  Submits a written guarantee acceptable to the agency
523	which is irrevocable during the term of the contracting entity's
524	contract with the agency and, upon termination of the contract,
525	until the agency receives proof of satisfaction of all
526	outstanding obligations incurred under the contract.
527	(18)(a)  The agency may require an entity contracting on a
528	prepaid or fixed-sum basis to establish a restricted insolvency
529	protection account with a federally guaranteed financial
530	institution licensed to do business in this state. The entity
531	shall deposit into that account 5 percent of the capitation
532	payments made by the agency each month until a maximum total of
533	2 percent of the total current contract amount is reached. The
534	restricted insolvency protection account may be drawn upon with
535	the authorized signatures of two persons designated by the
536	entity and two representatives of the agency. If the agency
537	finds that the entity is insolvent, the agency may draw upon the
538	account solely with the two authorized signatures of
539	representatives of the agency, and the funds may be disbursed to
540	meet financial obligations incurred by the entity under the
541	prepaid contract. If the contract is terminated, expired, or not
542	continued, the account balance must be released by the agency to
543	the entity upon receipt of proof of satisfaction of all
544	outstanding obligations incurred under this contract.
545	(b)  The agency may waive the insolvency protection account
546	requirement in writing when evidence is on file with the agency
547	of adequate insolvency insurance and reinsurance that will
548	protect enrollees if the entity becomes unable to meet its
549	obligations.
550	(19)  An entity that contracts with the agency on a prepaid
551	or fixed-sum basis for the provision of Medicaid services shall
552	reimburse any hospital or physician that is outside the entity's
553	authorized geographic service area as specified in its contract
554	with the agency, and that provides services authorized by the
555	entity to its members, at a rate negotiated with the hospital or
556	physician for the provision of services or according to the
557	lesser of the following:
558	(a)  The usual and customary charges made to the general
559	public by the hospital or physician; or
560	(b)  The Florida Medicaid reimbursement rate established
561	for the hospital or physician.
562	(20)  When a merger or acquisition of a Medicaid prepaid
563	contractor has been approved by the Office of Insurance
564	Regulation pursuant to s. 628.4615, the agency shall approve the
565	assignment or transfer of the appropriate Medicaid prepaid
566	contract upon request of the surviving entity of the merger or
567	acquisition if the contractor and the other entity have been in
568	good standing with the agency for the most recent 12-month
569	period, unless the agency determines that the assignment or
570	transfer would be detrimental to the Medicaid recipients or the
571	Medicaid program. To be in good standing, an entity must not
572	have failed accreditation or committed any material violation of
573	the requirements of s. 641.52 and must meet the Medicaid
574	contract requirements. For purposes of this section, a merger or
575	acquisition means a change in controlling interest of an entity,
576	including an asset or stock purchase.
577	(21)  Any entity contracting with the agency pursuant to
578	this section to provide health care services to Medicaid
579	recipients is prohibited from engaging in any of the following
580	practices or activities:
581	(a)  Practices that are discriminatory, including, but not
582	limited to, attempts to discourage participation on the basis of
583	actual or perceived health status.
584	(b)  Activities that could mislead or confuse recipients,
585	or misrepresent the organization, its marketing representatives,
586	or the agency. Violations of this paragraph include, but are not
587	limited to:
588	1.  False or misleading claims that marketing
589	representatives are employees or representatives of the state or
590	county, or of anyone other than the entity or the organization
591	by whom they are reimbursed.
592	2.  False or misleading claims that the entity is
593	recommended or endorsed by any state or county agency, or by any
594	other organization which has not certified its endorsement in
595	writing to the entity.
596	3.  False or misleading claims that the state or county
597	recommends that a Medicaid recipient enroll with an entity.
598	4.  Claims that a Medicaid recipient will lose benefits
599	under the Medicaid program, or any other health or welfare
600	benefits to which the recipient is legally entitled, if the
601	recipient does not enroll with the entity.
602	(c)  Granting or offering of any monetary or other valuable
603	consideration for enrollment, except as authorized by subsection
604	(22).
605	(d)  Door-to-door solicitation of recipients who have not
606	contacted the entity or who have not invited the entity to make
607	a presentation.
608	(e)  Solicitation of Medicaid recipients by marketing
609	representatives stationed in state offices unless approved and
610	supervised by the agency or its agent and approved by the
611	affected state agency when solicitation occurs in an office of
612	the state agency. The agency shall ensure that marketing
613	representatives stationed in state offices shall market their
614	managed care plans to Medicaid recipients only in designated
615	areas and in such a way as to not interfere with the recipients'
616	activities in the state office.
617	(f)  Enrollment of Medicaid recipients.
618	(22)  The agency may impose a fine for a violation of this
619	section or the contract with the agency by a person or entity
620	that is under contract with the agency. With respect to any
621	nonwillful violation, such fine shall not exceed $2,500 per
622	violation. In no event shall such fine exceed an aggregate
623	amount of $10,000 for all nonwillful violations arising out of
624	the same action. With respect to any knowing and willful
625	violation of this section or the contract with the agency, the
626	agency may impose a fine upon the entity in an amount not to
627	exceed $20,000 for each such violation. In no event shall such
628	fine exceed an aggregate amount of $100,000 for all knowing and
629	willful violations arising out of the same action.
630	(23)  A health maintenance organization or a person or
631	entity exempt from chapter 641 that is under contract with the
632	agency for the provision of health care services to Medicaid
633	recipients may not use or distribute marketing materials used to
634	solicit Medicaid recipients, unless such materials have been
635	approved by the agency. The provisions of this subsection do not
636	apply to general advertising and marketing materials used by a
637	health maintenance organization to solicit both non-Medicaid
638	subscribers and Medicaid recipients.
639	(24)  Upon approval by the agency, health maintenance
640	organizations and persons or entities exempt from chapter 641
641	that are under contract with the agency for the provision of
642	health care services to Medicaid recipients may be permitted
643	within the capitation rate to provide additional health benefits
644	that the agency has found are of high quality, are practicably
645	available, provide reasonable value to the recipient, and are
646	provided at no additional cost to the state.
647	(25)  The agency shall utilize the statewide health
648	maintenance organization complaint hotline for the purpose of
649	investigating and resolving Medicaid and prepaid health plan
650	complaints, maintaining a record of complaints and confirmed
651	problems, and receiving disenrollment requests made by
652	recipients.
653	(26)  The agency shall require the publication of the
654	health maintenance organization's and the prepaid health plan's
655	consumer services telephone numbers and the "800" telephone
656	number of the statewide health maintenance organization
657	complaint hotline on each Medicaid identification card issued by
658	a health maintenance organization or prepaid health plan
659	contracting with the agency to serve Medicaid recipients and on
660	each subscriber handbook issued to a Medicaid recipient.
661	(27)  The agency shall establish a health care quality
662	improvement system for those entities contracting with the
663	agency pursuant to this section, incorporating all the standards
664	and guidelines developed by the Medicaid Bureau of the Health
665	Care Financing Administration as a part of the quality assurance
666	reform initiative. The system shall include, but need not be
667	limited to, the following:
668	(a)  Guidelines for internal quality assurance programs,
669	including standards for:
670	1.  Written quality assurance program descriptions.
671	2.  Responsibilities of the governing body for monitoring,
672	evaluating, and making improvements to care.
673	3.  An active quality assurance committee.
674	4.  Quality assurance program supervision.
675	5.  Requiring the program to have adequate resources to
676	effectively carry out its specified activities.
677	6.  Provider participation in the quality assurance
678	program.
679	7.  Delegation of quality assurance program activities.
680	8.  Credentialing and recredentialing.
681	9.  Enrollee rights and responsibilities.
682	10.  Availability and accessibility to services and care.
683	11.  Ambulatory care facilities.
684	12.  Accessibility and availability of medical records, as
685	well as proper recordkeeping and process for record review.
686	13.  Utilization review.
687	14.  A continuity of care system.
688	15.  Quality assurance program documentation.
689	16.  Coordination of quality assurance activity with other
690	management activity.
691	17.  Delivering care to pregnant women and infants; to
692	elderly and disabled recipients, especially those who are at
693	risk of institutional placement; to persons with developmental
694	disabilities; and to adults who have chronic, high-cost medical
695	conditions.
696	(b)  Guidelines which require the entities to conduct
697	quality-of-care studies which:
698	1.  Target specific conditions and specific health service
699	delivery issues for focused monitoring and evaluation.
700	2.  Use clinical care standards or practice guidelines to
701	objectively evaluate the care the entity delivers or fails to
702	deliver for the targeted clinical conditions and health services
703	delivery issues.
704	3.  Use quality indicators derived from the clinical care
705	standards or practice guidelines to screen and monitor care and
706	services delivered.
707	(c)  Guidelines for external quality review of each
708	contractor which require: focused studies of patterns of care;
709	individual care review in specific situations; and followup
710	activities on previous pattern-of-care study findings and
711	individual-care-review findings. In designing the external
712	quality review function and determining how it is to operate as
713	part of the state's overall quality improvement system, the
714	agency shall construct its external quality review organization
715	and entity contracts to address each of the following:
716	1.  Delineating the role of the external quality review
717	organization.
718	2.  Length of the external quality review organization
719	contract with the state.
720	3.  Participation of the contracting entities in designing
721	external quality review organization review activities.
722	4.  Potential variation in the type of clinical conditions
723	and health services delivery issues to be studied at each plan.
724	5.  Determining the number of focused pattern-of-care
725	studies to be conducted for each plan.
726	6.  Methods for implementing focused studies.
727	7.  Individual care review.
728	8.  Followup activities.
729	(28)  In order to ensure that children receive health care
730	services for which an entity has already been compensated, an
731	entity contracting with the agency pursuant to this section
732	shall achieve an annual Early and Periodic Screening, Diagnosis,
733	and Treatment (EPSDT) Service screening rate of at least 60
734	percent for those recipients continuously enrolled for at least
735	8 months. The agency shall develop a method by which the EPSDT
736	screening rate shall be calculated. For any entity which does
737	not achieve the annual 60 percent rate, the entity must submit a
738	corrective action plan for the agency's approval. If the entity
739	does not meet the standard established in the corrective action
740	plan during the specified timeframe, the agency is authorized to
741	impose appropriate contract sanctions. At least annually, the
742	agency shall publicly release the EPSDT Services screening rates
743	of each entity it has contracted with on a prepaid basis to
744	serve Medicaid recipients.
745	(29)  The agency shall perform enrollments and
746	disenrollments for Medicaid recipients who are eligible for
747	MediPass or managed care plans. Notwithstanding the prohibition
748	contained in paragraph (19)(f), managed care plans may perform
749	preenrollments of Medicaid recipients under the supervision of
750	the agency or its agents. For the purposes of this section,
751	"preenrollment" means the provision of marketing and educational
752	materials to a Medicaid recipient and assistance in completing
753	the application forms, but shall not include actual enrollment
754	into a managed care plan. An application for enrollment shall
755	not be deemed complete until the agency or its agent verifies
756	that the recipient made an informed, voluntary choice. The
757	agency, in cooperation with the Department of Children and
758	Family Services, may test new marketing initiatives to inform
759	Medicaid recipients about their managed care options at selected
760	sites. The agency shall report to the Legislature on the
761	effectiveness of such initiatives. The agency may contract with
762	a third party to perform managed care plan and MediPass
763	enrollment and disenrollment services for Medicaid recipients
764	and is authorized to adopt rules to implement such services. The
765	agency may adjust the capitation rate only to cover the costs of
766	a third-party enrollment and disenrollment contract, and for
767	agency supervision and management of the managed care plan
768	enrollment and disenrollment contract.
769	(30)  Any lists of providers made available to Medicaid
770	recipients, MediPass enrollees, or managed care plan enrollees
771	shall be arranged alphabetically showing the provider's name and
772	specialty and, separately, by specialty in alphabetical order.
773	(31)  The agency shall establish an enhanced managed care
774	quality assurance oversight function, to include at least the
775	following components:
776	(a)  At least quarterly analysis and followup, including
777	sanctions as appropriate, of managed care participant
778	utilization of services.
779	(b)  At least quarterly analysis and followup, including
780	sanctions as appropriate, of quality findings of the Medicaid
781	peer review organization and other external quality assurance
782	programs.
783	(c)  At least quarterly analysis and followup, including
784	sanctions as appropriate, of the fiscal viability of managed
785	care plans.
786	(d)  At least quarterly analysis and followup, including
787	sanctions as appropriate, of managed care participant
788	satisfaction and disenrollment surveys.
789	(e)  The agency shall conduct regular and ongoing Medicaid
790	recipient satisfaction surveys.
791
792	The analyses and followup activities conducted by the agency
793	under its enhanced managed care quality assurance oversight
794	function shall not duplicate the activities of accreditation
795	reviewers for entities regulated under part III of chapter 641,
796	but may include a review of the finding of such reviewers.
797	(32)  Each managed care plan that is under contract with
798	the agency to provide health care services to Medicaid
799	recipients shall annually conduct a background check with the
800	Florida Department of Law Enforcement of all persons with
801	ownership interest of 5 percent or more or executive management
802	responsibility for the managed care plan and shall submit to the
803	agency information concerning any such person who has been found
804	guilty of, regardless of adjudication, or has entered a plea of
805	nolo contendere or guilty to, any of the offenses listed in s.
806	435.03.
807	(33)  The agency shall, by rule, develop a process whereby
808	a Medicaid managed care plan enrollee who wishes to enter
809	hospice care may be disenrolled from the managed care plan
810	within 24 hours after contacting the agency regarding such
811	request. The agency rule shall include a methodology for the
812	agency to recoup managed care plan payments on a pro rata basis
813	if payment has been made for the enrollment month when
814	disenrollment occurs.
815	(34)  The agency and entities which contract with the
816	agency to provide health care services to Medicaid recipients
817	under this section or s. 409.9122 must comply with the
818	provisions of s. 641.513 in providing emergency services and
819	care to Medicaid recipients and MediPass recipients.
820	(35)  All entities providing health care services to
821	Medicaid recipients shall make available, and encourage all
822	pregnant women and mothers with infants to receive, and provide
823	documentation in the medical records to reflect, the following:
824	(a)  Healthy Start prenatal or infant screening.
825	(b)  Healthy Start care coordination, when screening or
826	other factors indicate need.
827	(c)  Healthy Start enhanced services in accordance with the
828	prenatal or infant screening results.
829	(d)  Immunizations in accordance with recommendations of
830	the Advisory Committee on Immunization Practices of the United
831	States Public Health Service and the American Academy of
832	Pediatrics, as appropriate.
833	(e)  Counseling and services for family planning to all
834	women and their partners.
835	(f)  A scheduled postpartum visit for the purpose of
836	voluntary family planning, to include discussion of all methods
837	of contraception, as appropriate.
838	(g)  Referral to the Special Supplemental Nutrition Program
839	for Women, Infants, and Children (WIC).
840	(36)  Any entity that provides Medicaid prepaid health plan
841	services shall ensure the appropriate coordination of health
842	care services with an assisted living facility in cases where a
843	Medicaid recipient is both a member of the entity's prepaid
844	health plan and a resident of the assisted living facility. If
845	the entity is at risk for Medicaid targeted case management and
846	behavioral health services, the entity shall inform the assisted
847	living facility of the procedures to follow should an emergent
848	condition arise.
849	(37)  The agency may seek and implement federal waivers
850	necessary to provide for cost-effective purchasing of home
851	health services, private duty nursing services, transportation,
852	independent laboratory services, and durable medical equipment
853	and supplies through competitive bidding pursuant to s. 287.057.
854	The agency may request appropriate waivers from the federal
855	Health Care Financing Administration in order to competitively
856	bid such services. The agency may exclude providers not selected
857	through the bidding process from the Medicaid provider network.
858	(38)  The Agency for Health Care Administration is directed
859	to issue a request for proposal or intent to negotiate to
860	implement on a demonstration basis an outpatient specialty
861	services pilot project in a rural and urban county in the state.
862	As used in this subsection, the term "outpatient specialty
863	services" means clinical laboratory, diagnostic imaging, and
864	specified home medical services to include durable medical
865	equipment, prosthetics and orthotics, and infusion therapy.
866	(a)  The entity that is awarded the contract to provide
867	Medicaid managed care outpatient specialty services must, at a
868	minimum, meet the following criteria:
869	1.  The entity must be licensed by the Office of Insurance
870	Regulation under part II of chapter 641.
871	2.  The entity must be experienced in providing outpatient
872	specialty services.
873	3.  The entity must demonstrate to the satisfaction of the
874	agency that it provides high-quality services to its patients.
875	4.  The entity must demonstrate that it has in place a
876	complaints and grievance process to assist Medicaid recipients
877	enrolled in the pilot managed care program to resolve complaints
878	and grievances.
879	(b)  The pilot managed care program shall operate for a
880	period of 3 years. The objective of the pilot program shall be
881	to determine the cost-effectiveness and effects on utilization,
882	access, and quality of providing outpatient specialty services
883	to Medicaid recipients on a prepaid, capitated basis.
884	(c)  The agency shall conduct a quality assurance review of
885	the prepaid health clinic each year that the demonstration
886	program is in effect. The prepaid health clinic is responsible
887	for all expenses incurred by the agency in conducting a quality
888	assurance review.
889	(d)  The entity that is awarded the contract to provide
890	outpatient specialty services to Medicaid recipients shall
891	report data required by the agency in a format specified by the
892	agency, for the purpose of conducting the evaluation required in
893	paragraph (e).
894	(e)  The agency shall conduct an evaluation of the pilot
895	managed care program and report its findings to the Governor and
896	the Legislature by no later than January 1, 2001.
897	(39)  The agency shall enter into agreements with not-for-
898	profit organizations based in this state for the purpose of
899	providing vision screening.
900	(40)(a)  The agency shall implement a Medicaid prescribed-
901	drug spending-control program that includes the following
902	components:
903	1.  Medicaid prescribed-drug coverage for brand-name drugs
904	for adult Medicaid recipients is limited to the dispensing of
905	four brand-name drugs per month per recipient. Children are
906	exempt from this restriction. Antiretroviral agents are excluded
907	from this limitation. No requirements for prior authorization or
908	other restrictions on medications used to treat mental illnesses
909	such as schizophrenia, severe depression, or bipolar disorder
910	may be imposed on Medicaid recipients. Medications that will be
911	available without restriction for persons with mental illnesses
912	include atypical antipsychotic medications, conventional
913	antipsychotic medications, selective serotonin reuptake
914	inhibitors, and other medications used for the treatment of
915	serious mental illnesses. The agency shall also limit the amount
916	of a prescribed drug dispensed to no more than a 34-day supply.
917	The agency shall continue to provide unlimited generic drugs,
918	contraceptive drugs and items, and diabetic supplies. Although a
919	drug may be included on the preferred drug formulary, it would
920	not be exempt from the four-brand limit. The agency may
921	authorize exceptions to the brand-name-drug restriction based
922	upon the treatment needs of the patients, only when such
923	exceptions are based on prior consultation provided by the
924	agency or an agency contractor, but the agency must establish
925	procedures to ensure that:
926	a.  There will be a response to a request for prior
927	consultation by telephone or other telecommunication device
928	within 24 hours after receipt of a request for prior
929	consultation;
930	b.  A 72-hour supply of the drug prescribed will be
931	provided in an emergency or when the agency does not provide a
932	response within 24 hours as required by sub-subparagraph a.; and
933	c.  Except for the exception for nursing home residents and
934	other institutionalized adults and except for drugs on the
935	restricted formulary for which prior authorization may be sought
936	by an institutional or community pharmacy, prior authorization
937	for an exception to the brand-name-drug restriction is sought by
938	the prescriber and not by the pharmacy. When prior authorization
939	is granted for a patient in an institutional setting beyond the
940	brand-name-drug restriction, such approval is authorized for 12
941	months and monthly prior authorization is not required for that
942	patient.
943	2.  Reimbursement to pharmacies for Medicaid prescribed
944	drugs shall be set at the average wholesale price less 13.25
945	percent.
946	3.  The agency shall develop and implement a process for
947	managing the drug therapies of Medicaid recipients who are using
948	significant numbers of prescribed drugs each month. The
949	management process may include, but is not limited to,
950	comprehensive, physician-directed medical-record reviews, claims
951	analyses, and case evaluations to determine the medical
952	necessity and appropriateness of a patient's treatment plan and
953	drug therapies. The agency may contract with a private
954	organization to provide drug-program-management services. The
955	Medicaid drug benefit management program shall include
956	initiatives to manage drug therapies for HIV/AIDS patients,
957	patients using 20 or more unique prescriptions in a 180-day
958	period, and the top 1,000 patients in annual spending.
959	4.  The agency may limit the size of its pharmacy network
960	based on need, competitive bidding, price negotiations,
961	credentialing, or similar criteria. The agency shall give
962	special consideration to rural areas in determining the size and
963	location of pharmacies included in the Medicaid pharmacy
964	network. A pharmacy credentialing process may include criteria
965	such as a pharmacy's full-service status, location, size,
966	patient educational programs, patient consultation, disease-
967	management services, and other characteristics. The agency may
968	impose a moratorium on Medicaid pharmacy enrollment when it is
969	determined that it has a sufficient number of Medicaid-
970	participating providers.
971	5.  The agency shall develop and implement a program that
972	requires Medicaid practitioners who prescribe drugs to use a
973	counterfeit-proof prescription pad for Medicaid prescriptions.
974	The agency shall require the use of standardized counterfeit-
975	proof prescription pads by Medicaid-participating prescribers or
976	prescribers who write prescriptions for Medicaid recipients. The
977	agency may implement the program in targeted geographic areas or
978	statewide.
979	6.  The agency may enter into arrangements that require
980	manufacturers of generic drugs prescribed to Medicaid recipients
981	to provide rebates of at least 15.1 percent of the average
982	manufacturer price for the manufacturer's generic products.
983	These arrangements shall require that if a generic-drug
984	manufacturer pays federal rebates for Medicaid-reimbursed drugs
985	at a level below 15.1 percent, the manufacturer must provide a
986	supplemental rebate to the state in an amount necessary to
987	achieve a 15.1-percent rebate level.
988	7.  The agency may establish a preferred drug formulary in
989	accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the
990	establishment of such formulary, it is authorized to negotiate
991	supplemental rebates from manufacturers that are in addition to
992	those required by Title XIX of the Social Security Act and at no
993	less than 10 percent of the average manufacturer price as
994	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
995	the federal or supplemental rebate, or both, equals or exceeds
996	25 percent. There is no upper limit on the supplemental rebates
997	the agency may negotiate. The agency may determine that specific
998	products, brand-name or generic, are competitive at lower rebate
999	percentages. Agreement to pay the minimum supplemental rebate
1000	percentage will guarantee a manufacturer that the Medicaid
1001	Pharmaceutical and Therapeutics Committee will consider a
1002	product for inclusion on the preferred drug formulary. However,
1003	a pharmaceutical manufacturer is not guaranteed placement on the
1004	formulary by simply paying the minimum supplemental rebate.
1005	Agency decisions will be made on the clinical efficacy of a drug
1006	and recommendations of the Medicaid Pharmaceutical and
1007	Therapeutics Committee, as well as the price of competing
1008	products minus federal and state rebates. The agency is
1009	authorized to contract with an outside agency or contractor to
1010	conduct negotiations for supplemental rebates. For the purposes
1011	of this section, the term "supplemental rebates" may include, at
1012	the agency's discretion, cash rebates and other program benefits
1013	that offset a Medicaid expenditure. Such other program benefits
1014	may include, but are not limited to, disease management
1015	programs, drug product donation programs, drug utilization
1016	control programs, prescriber and beneficiary counseling and
1017	education, fraud and abuse initiatives, and other services or
1018	administrative investments with guaranteed savings to the
1019	Medicaid program in the same year the rebate reduction is
1020	included in the General Appropriations Act. The agency is
1021	authorized to seek any federal waivers to implement this
1022	initiative.
1023	8.  The agency shall establish an advisory committee for
1024	the purposes of studying the feasibility of using a restricted
1025	drug formulary for nursing home residents and other
1026	institutionalized adults. The committee shall be comprised of
1027	seven members appointed by the Secretary of Health Care
1028	Administration. The committee members shall include two
1029	physicians licensed under chapter 458 or chapter 459; three
1030	pharmacists licensed under chapter 465 and appointed from a list
1031	of recommendations provided by the Florida Long-Term Care
1032	Pharmacy Alliance; and two pharmacists licensed under chapter
1033	465.
1034	9.  The Agency for Health Care Administration shall expand
1035	home delivery of pharmacy products. To assist Medicaid patients
1036	in securing their prescriptions and reduce program costs, the
1037	agency shall expand its current mail-order-pharmacy diabetes-
1038	supply program to include all generic and brand-name drugs used
1039	by Medicaid patients with diabetes. Medicaid recipients in the
1040	current program may obtain nondiabetes drugs on a voluntary
1041	basis. This initiative is limited to the geographic area covered
1042	by the current contract. The agency may seek and implement any
1043	federal waivers necessary to implement this subparagraph.
1044	(b)  The agency shall implement this subsection to the
1045	extent that funds are appropriated to administer the Medicaid
1046	prescribed-drug spending-control program. The agency may
1047	contract all or any part of this program to private
1048	organizations.
1049	(c)  The agency shall submit quarterly reports to the
1050	Governor, the President of the Senate, and the Speaker of the
1051	House of Representatives which must include, but need not be
1052	limited to, the progress made in implementing this subsection
1053	and its effect on Medicaid prescribed-drug expenditures.
1054	(41)  Notwithstanding the provisions of chapter 287, the
1055	agency may, at its discretion, renew a contract or contracts for
1056	fiscal intermediary services one or more times for such periods
1057	as the agency may decide; however, all such renewals may not
1058	combine to exceed a total period longer than the term of the
1059	original contract.
1060	(42)  The agency shall provide for the development of a
1061	demonstration project by establishment in Miami-Dade County of a
1062	long-term-care facility licensed pursuant to chapter 395 to
1063	improve access to health care for a predominantly minority,
1064	medically underserved, and medically complex population and to
1065	evaluate alternatives to nursing home care and general acute
1066	care for such population. Such project is to be located in a
1067	health care condominium and colocated with licensed facilities
1068	providing a continuum of care. The establishment of this project
1069	is not subject to the provisions of s. 408.036 or s. 408.039.
1070	The agency shall report its findings to the Governor, the
1071	President of the Senate, and the Speaker of the House of
1072	Representatives by January 1, 2003.
1073	(43)  The agency shall develop and implement a utilization
1074	management program for Medicaid-eligible recipients for the
1075	management of occupational, physical, respiratory, and speech
1076	therapies. The agency shall establish a utilization program that
1077	may require prior authorization in order to ensure medically
1078	necessary and cost-effective treatments. The program shall be
1079	operated in accordance with a federally approved waiver program
1080	or state plan amendment. The agency may seek a federal waiver or
1081	state plan amendment to implement this program. The agency may
1082	also competitively procure these services from an outside vendor
1083	on a regional or statewide basis.
1084	(44)  The agency may contract on a prepaid or fixed-sum
1085	basis with appropriately licensed prepaid dental health plans to
1086	provide dental services.
1087	Section 3.  Paragraphs (f) and (k) of subsection (2) of
1088	section 409.9122, Florida Statutes, are amended to read:
1089	409.9122  Mandatory Medicaid managed care enrollment;
1090	programs and procedures.--
1091	(2)
1092	(f)  When a Medicaid recipient does not choose a managed
1093	care plan or MediPass provider, the agency shall assign the
1094	Medicaid recipient to a managed care plan to the extent capacity
1095	in such plan allows or to a MediPass provider if all managed
1096	care plans have reached capacity. Medicaid recipients who are
1097	subject to mandatory assignment but who fail to make a choice
1098	shall be assigned to managed care plans until an enrollment of
1099	40 percent in MediPass and 60 percent in managed care plans is
1100	achieved. Once this enrollment is achieved, the assignments
1101	shall be divided in order to maintain an enrollment in MediPass
1102	and managed care plans which is in a 40 percent and 60 percent
1103	proportion, respectively. Thereafter, assignment of Medicaid
1104	recipients who fail to make a choice shall be based
1105	proportionally on the preferences of recipients who have made a
1106	choice in the previous period. Such proportions shall be revised
1107	at least quarterly to reflect an update of the preferences of
1108	Medicaid recipients. The agency shall disproportionately assign
1109	Medicaid-eligible recipients who are required to but have failed
1110	to make a choice of managed care plan or MediPass, including
1111	children, and who are to be assigned to the MediPass program to
1112	children's networks as described in s. 409.912(3)(g), Children's
1113	Medical Services network as defined in s. 391.021, exclusive
1114	provider organizations, provider service networks, minority
1115	physician networks, and pediatric emergency department diversion
1116	programs authorized by this chapter or the General
1117	Appropriations Act, in such manner as the agency deems
1118	appropriate, until the agency has determined that the networks
1119	and programs have sufficient numbers to be economically
1120	operated. For purposes of this paragraph, when referring to
1121	assignment, the term "managed care plans" includes health
1122	maintenance organizations, exclusive provider organizations,
1123	provider service networks, minority physician networks,
1124	Children's Medical Services network, and pediatric emergency
1125	department diversion programs authorized by this chapter or the
1126	General Appropriations Act. When making assignments, the agency
1127	shall take into account the following criteria:
1128	1.  A managed care plan has sufficient network capacity to
1129	meet the need of members.
1130	2.  The managed care plan or MediPass has previously
1131	enrolled the recipient as a member, or one of the managed care
1132	plan's primary care providers or MediPass providers has
1133	previously provided health care to the recipient.
1134	3.  The agency has knowledge that the member has previously
1135	expressed a preference for a particular managed care plan or
1136	MediPass provider as indicated by Medicaid fee-for-service
1137	claims data, but has failed to make a choice.
1138	4.  The managed care plan's or MediPass primary care
1139	providers are geographically accessible to the recipient's
1140	residence.
1141	(k)  When a Medicaid recipient does not choose a managed
1142	care plan or MediPass provider, the agency shall assign the
1143	Medicaid recipient to a managed care plan, except in those
1144	counties in which there are fewer than two managed care plans
1145	accepting Medicaid enrollees, in which case assignment shall be
1146	to a managed care plan or a MediPass provider. Medicaid
1147	recipients in counties with fewer than two managed care plans
1148	accepting Medicaid enrollees who are subject to mandatory
1149	assignment but who fail to make a choice shall be assigned to
1150	managed care plans until an enrollment of 40 percent in MediPass
1151	and 60 percent in managed care plans is achieved. Once that
1152	enrollment is achieved, the assignments shall be divided in
1153	order to maintain an enrollment in MediPass and managed care
1154	plans which is in a 40 percent and 60 percent proportion,
1155	respectively. In geographic areas where the agency is
1156	contracting for the provision of comprehensive behavioral health
1157	services through a capitated prepaid arrangement, recipients who
1158	fail to make a choice shall be assigned equally to MediPass or a
1159	managed care plan. For purposes of this paragraph, when
1160	referring to assignment, the term "managed care plans" includes
1161	exclusive provider organizations, provider service networks,
1162	Children's Medical Services network, minority physician
1163	networks, and pediatric emergency department diversion programs
1164	authorized by this chapter or the General Appropriations Act.
1165	When making assignments, the agency shall take into account the
1166	following criteria:
1167	1.  A managed care plan has sufficient network capacity to
1168	meet the need of members.
1169	2.  The managed care plan or MediPass has previously
1170	enrolled the recipient as a member, or one of the managed care
1171	plan's primary care providers or MediPass providers has
1172	previously provided health care to the recipient.
1173	3.  The agency has knowledge that the member has previously
1174	expressed a preference for a particular managed care plan or
1175	MediPass provider as indicated by Medicaid fee-for-service
1176	claims data, but has failed to make a choice.
1177	4.  The managed care plan's or MediPass primary care
1178	providers are geographically accessible to the recipient's
1179	residence.
1180	5.  The agency has authority to make mandatory assignments
1181	based on quality of service and performance of managed care
1182	plans.
1183	Section 4.  Whenever possible and allowable under federal
1184	law, and by contract pursuant to s. 287.057, Florida Statutes,
1185	the Agency for Health Care Administration shall outsource
1186	routine functions that pertain to the administration of the
1187	Medicaid program.
1188	Section 5.  (1)  By October 1, 2004, the Agency for Health
1189	Care Administration shall contract with an actuarial firm to
1190	evaluate the agency's current Medicaid reimbursement
1191	methodologies and provide recommendations on the most efficient
1192	reimbursement methodologies available to the agency. The agency
1193	shall report to the President of the Senate and the Speaker of
1194	the House of Representatives no later than October 1, 2005, on
1195	the results of the evaluation, including such recommendations,
1196	and shall provide the agency's recommendation of the most
1197	efficient reimbursement methodology for the agency to use.
1198	(2)  The agency shall conduct a study to design and
1199	implement a standard for handling Medicaid records
1200	electronically. In conducting the study, the agency may work
1201	with the United States Department of Health and Human Services
1202	and other states' departments responsible for administering the
1203	Medicaid program.
1204	Section 6.  There is hereby appropriated from the General
1205	Revenue Fund to the Agency for Health Care Administration an
1206	amount sufficient to carry out the provisions of this act.
1207	Section 7.  This act shall take effect July 1, 2004.

CODING: Words stricken are deletions; words underlined are additions.