HB 5085

1	A bill to be entitled
2	An act relating to health care; transferring and
3	reassigning certain functions and responsibilities,
4	including records, personnel, property, and unexpended
5	balances of appropriations and other resources, from the
6	Department of Health to the Department of Business and
7	Professional Regulation by a type two transfer; providing
8	for the continued validity of pending judicial or
9	administrative actions to which the Department of Health
10	is a party; providing for the continued validity of lawful
11	orders issued by the Department of Health; transferring
12	rules created by the Department of Health to the
13	Department of Business and Professional Regulation;
14	providing for the continued validity of permits and
15	certifications issued by the Department of Health;
16	amending s. 400.179, F.S.; authorizing the Agency for
17	Health Care Administration to transfer funds to the Grants
18	and Donations Trust Fund for certain repayments; amending
19	s. 400.23, F.S.; providing minimum staffing requirements
20	for nursing homes for a specified period; amending s.
21	409.905, F.S.; prohibiting payment for certain hospital
22	inpatient per diem rate adjustment for 2 fiscal years;
23	amending s. 409.906, F.S.; prohibiting payment for
24	Medicaid chiropractic services, hospice care services, and
25	podiatric services for 2 fiscal years; authorizing payment
26	of a specified amount for Medicaid services provided by an
27	anesthesiologist assistant; amending s. 409.908, F.S.;
28	deleting a provision prohibiting Medicaid from making any
29	payment toward deductibles and coinsurance for services
30	not covered by Medicaid; providing limitations on Medicaid
31	payments for coinsurance; revising reimbursement rates for
32	providers of Medicaid prescribed drugs; requiring the
33	agency to revise reimbursement rates for hospitals,
34	nursing homes, county health departments, and community
35	intermediate care facilities for the developmentally
36	disabled for 2 fiscal years; requiring the agency to apply
37	the effect of the revised reimbursement rates to set
38	payment rates for managed care plans and nursing home
39	diversion programs; requiring the agency to establish
40	workgroups to evaluate alternative reimbursement and
41	payment methodologies for hospitals, nursing facilities,
42	and managed care plans; requiring a report; providing for
43	future repeal of the suspension of the use of cost data to
44	set certain rates; amending s. 409.911, F.S.; revising the
45	share data used to calculate disproportionate share
46	payments to hospitals; amending s. 409.9112, F.S.;
47	revising the time period during which the agency is
48	prohibited from distributing disproportionate share
49	payments to regional perinatal intensive care centers;
50	amending s. 409.9113, F.S.; requiring the agency to
51	distribute moneys provided in the General Appropriations
52	Act to statutorily defined teaching hospitals and family
53	practice teaching hospitals under the teaching hospital
54	disproportionate share program for the 2008-2009 fiscal
55	year; amending s. 409.9117, F.S.; prohibiting the agency
56	from distributing moneys under the primary care
57	disproportionate share program for the 2008-2009 fiscal
58	year; amending s. 409.912, F.S.; adding a county for
59	participation in the Medicaid behavioral health care
60	services specialty prepaid plan; revising reimbursement
61	rates to pharmacies for Medicaid prescribed drugs;
62	requiring the agency to notify the Legislature before
63	seeking an amendment to the state plan in order to
64	implement programs authorized by the Deficit Reduction Act
65	of 2005; creating s. 409.91206, F.S.; providing for
66	proposed alternatives for health and long-term care
67	reforms; amending s. 409.91211, F.S.; providing for
68	expansion of the Medicaid managed care pilot program to
69	Hardee, Highlands, Hillsborough, Manatee, Miami-Dade,
70	Monroe, Pasco, Pinellas, and Polk Counties; permitting
71	fee-for-service provider service networks to be reimbursed
72	on a risk-adjusted capitated basis for certain services;
73	requiring the agency to encourage cost-effective
74	administration by provider service networks; requiring
75	quarterly monitoring and annual evaluation of plan network
76	adequacy; requiring that Medicaid recipients receive
77	prescription drug coverage information for each plan;
78	requiring the agency to set standards for prompt claims
79	payment; revising assignment processes for certain
80	recipients; amending s. 409.9124, F.S.; removing the
81	limitation on the application of certain rates and rate
82	reductions used by the agency to reimburse managed care
83	plans; amending s. 409.913, F.S.; prohibiting mailing of
84	the explanation of benefits for certain Medicaid services;
85	repealing s. 381.0271, F.S., relating to the Florida
86	Patient Safety Corporation; repealing s. 381.0273, F.S.,
87	relating to public records exemption for patient safety
88	data; repealing s. 394.4595, F.S., relating to access to
89	patient records by the Florida statewide and local
90	advocacy councils; repealing s. 402.164, F.S., relating to
91	the Florida Statewide Advocacy Council and the Florida
92	local advocacy councils; repealing s. 402.165, F.S.,
93	relating to the Florida Statewide Advocacy Council;
94	repealing s. 402.166, F.S., relating to Florida local
95	advocacy councils; repealing s. 402.167, F.S., relating to
96	duties of state agencies that provide client services
97	relating to the Florida Statewide Advocacy Council and the
98	Florida local advocacy councils; repealing s. 409.9061,
99	F.S., relating to authority for a statewide laboratory
100	services contract; repealing s. 430.80, F.S., relating to
101	implementation of a teaching nursing home pilot project;
102	repealing s. 430.83, F.S., relating to the Sunshine for
103	Seniors Program; repealing ss. 464.0195, 464.0196, and
104	464.0197, F.S., relating to the Florida Center for
105	Nursing; repealing s. 464.0198, F.S., relating to the
106	Florida Center for Nursing Trust Fund; amending ss.
107	39.001, 39.0011, 39.202, 39.302, 215.22, 394.459,
108	394.4597, 394.4598, 394.4599, 394.4615, 400.0065, 400.118,
109	400.141, 415.1034, 415.104, 415.1055, 415.106, 415.107,
110	429.19, 429.28, 429.34, and 430.04, F.S.; conforming
111	provisions and correcting cross-references; providing an
112	effective date.
113
114	Be It Enacted by the Legislature of the State of Florida:
115
116	Section 1.  (1)  Effective April 1, 2009, all of the
117	statutory powers, duties and functions, records, personnel,
118	property, and unexpended balances of appropriations,
119	allocations, or other funds for the administration of part I of
120	chapter 499, Florida Statutes, relating to drugs, devices,
121	cosmetics, and household products shall be transferred by a type
122	two transfer, as defined in s. 20.06(2), Florida Statutes, from
123	the Department of Health to the Department of Business and
124	Professional Regulation.
125	(2)  The transfer of regulatory authority under part I of
126	chapter 499, Florida Statutes, provided by this act shall not
127	affect the validity of any judicial or administrative action
128	pending as of 11:59 p.m. on the day before the effective date of
129	this act to which the Department of Health is at that time a
130	party, and the Department of Business and Professional
131	Regulation shall be substituted as a party in interest in any
132	such action.
133	(3)  All lawful orders issued by the Department of Health
134	implementing or enforcing or otherwise in regard to any
135	provision of part I of chapter 499, Florida Statutes, issued
136	prior to the effective date of this act shall remain in effect
137	and be enforceable after the effective date of this act unless
138	thereafter modified in accordance with law.
139	(4)  The rules of the Department of Health relating to the
140	implementation of part I of chapter 499, Florida Statutes, that
141	were in effect at 11:59 p.m. on the day prior to this act taking
142	effect shall become the rules of the Department of Business and
143	Professional Regulation and shall remain in effect until amended
144	or repealed in the manner provided by law.
145	(5)  Notwithstanding the transfer of regulatory authority
146	under part I of chapter 499, Florida Statutes, provided by this
147	act, persons and entities holding in good standing any permit
148	under part I of chapter 499, Florida Statutes, as of 11:59 p.m.
149	on the day prior to the effective date of this act shall, as of
150	the effective date of this act, be deemed to hold in good
151	standing a permit in the same capacity as that for which the
152	permit was formerly issued.
153	(6)  Notwithstanding the transfer of regulatory authority
154	under part I of chapter 499, Florida Statutes, provided by this
155	act, persons holding in good standing any certification under
156	part I of chapter 499, Florida Statutes, as of 11:59 p.m. on the
157	day prior to the effective date of this act shall, as of the
158	effective date of this act, be deemed to be certified in the
159	same capacity in which they were formerly certified.
160	Section 2.  Paragraph (d) of subsection (2) of section
161	400.179, Florida Statutes, is amended to read:
162	400.179  Liability for Medicaid underpayments and
163	overpayments.--
164	(2)  Because any transfer of a nursing facility may expose
165	the fact that Medicaid may have underpaid or overpaid the
166	transferor, and because in most instances, any such underpayment
167	or overpayment can only be determined following a formal field
168	audit, the liabilities for any such underpayments or
169	overpayments shall be as follows:
170	(d)  Where the transfer involves a facility that has been
171	leased by the transferor:
172	1.  The transferee shall, as a condition to being issued a
173	license by the agency, acquire, maintain, and provide proof to
174	the agency of a bond with a term of 30 months, renewable
175	annually, in an amount not less than the total of 3 months'
176	Medicaid payments to the facility computed on the basis of the
177	preceding 12-month average Medicaid payments to the facility.
178	2.  A leasehold licensee may meet the requirements of
179	subparagraph 1. by payment of a nonrefundable fee, paid at
180	initial licensure, paid at the time of any subsequent change of
181	ownership, and paid annually thereafter, in the amount of 1
182	percent of the total of 3 months' Medicaid payments to the
183	facility computed on the basis of the preceding 12-month average
184	Medicaid payments to the facility. If a preceding 12-month
185	average is not available, projected Medicaid payments may be
186	used. The fee shall be deposited into the Health Care Trust Fund
187	and shall be accounted for separately as a Medicaid nursing home
188	overpayment account. These fees shall be used at the sole
189	discretion of the agency to repay nursing home Medicaid
190	overpayments. The agency is authorized to transfer funds to the
191	Grants and Donations Trust Fund for such repayments. Payment of
192	this fee shall not release the licensee from any liability for
193	any Medicaid overpayments, nor shall payment bar the agency from
194	seeking to recoup overpayments from the licensee and any other
195	liable party. As a condition of exercising this lease bond
196	alternative, licensees paying this fee must maintain an existing
197	lease bond through the end of the 30-month term period of that
198	bond. The agency is herein granted specific authority to
199	promulgate all rules pertaining to the administration and
200	management of this account, including withdrawals from the
201	account, subject to federal review and approval. This provision
202	shall take effect upon becoming law and shall apply to any
203	leasehold license application. The financial viability of the
204	Medicaid nursing home overpayment account shall be determined by
205	the agency through annual review of the account balance and the
206	amount of total outstanding, unpaid Medicaid overpayments owing
207	from leasehold licensees to the agency as determined by final
208	agency audits.
209	3.  The leasehold licensee may meet the bond requirement
210	through other arrangements acceptable to the agency. The agency
211	is herein granted specific authority to promulgate rules
212	pertaining to lease bond arrangements.
213	4.  All existing nursing facility licensees, operating the
214	facility as a leasehold, shall acquire, maintain, and provide
215	proof to the agency of the 30-month bond required in
216	subparagraph 1., above, on and after July 1, 1993, for each
217	license renewal.
218	5.  It shall be the responsibility of all nursing facility
219	operators, operating the facility as a leasehold, to renew the
220	30-month bond and to provide proof of such renewal to the agency
221	annually.
222	6.  Any failure of the nursing facility operator to
223	acquire, maintain, renew annually, or provide proof to the
224	agency shall be grounds for the agency to deny, revoke, and
225	suspend the facility license to operate such facility and to
226	take any further action, including, but not limited to,
227	enjoining the facility, asserting a moratorium pursuant to part
228	II of chapter 408, or applying for a receiver, deemed necessary
229	to ensure compliance with this section and to safeguard and
230	protect the health, safety, and welfare of the facility's
231	residents. A lease agreement required as a condition of bond
232	financing or refinancing under s. 154.213 by a health facilities
233	authority or required under s. 159.30 by a county or
234	municipality is not a leasehold for purposes of this paragraph
235	and is not subject to the bond requirement of this paragraph.
236	Section 3.  Paragraph (a) of subsection (3) of section
237	400.23, Florida Statutes, is amended to read:
238	400.23  Rules; evaluation and deficiencies; licensure
239	status.--
240	(3)(a)1.  The agency shall adopt rules providing minimum
241	staffing requirements for nursing homes. These requirements
242	shall include, for each nursing home facility:
243	a.  A minimum certified nursing assistant staffing of 2.6
244	hours of direct care per resident per day beginning January 1,
245	2003, and increasing to 2.7 hours of direct care per resident
246	per day beginning January 1, 2007. Beginning January 1, 2002, no
247	facility shall staff below one certified nursing assistant per
248	20 residents, and a minimum licensed nursing staffing of 1.0
249	hour of direct care per resident per day but never below one
250	licensed nurse per 40 residents.
251	b.  Beginning January 1, 2007, a minimum weekly average
252	certified nursing assistant staffing of 2.9 hours of direct care
253	per resident per day. For the purpose of this sub-subparagraph,
254	a week is defined as Sunday through Saturday.
255	c.  Beginning July 1, 2008, and ending June 30, 2010, a
256	minimum daily combined average certified nursing assistant and
257	licensed nursing staffing of 3.7 hours of direct care per
258	resident per day, with a minimum certified nursing assistant
259	staffing of 2.6 hours of direct care per resident per day and a
260	minimum licensed nursing staffing of 1.0 hour of direct care per
261	resident per day. No facility shall staff below one certified
262	nursing assistant per 20 residents and one licensed nurse per 40
263	residents.
264	2.  Nursing assistants employed under s. 400.211(2) may be
265	included in computing the staffing ratio for certified nursing
266	assistants only if their job responsibilities include only
267	nursing-assistant-related duties.
268	3.  Each nursing home must document compliance with
269	staffing standards as required under this paragraph and post
270	daily the names of staff on duty for the benefit of facility
271	residents and the public.
272	4.  The agency shall recognize the use of licensed nurses
273	for compliance with minimum staffing requirements for certified
274	nursing assistants, provided that the facility otherwise meets
275	the minimum staffing requirements for licensed nurses and that
276	the licensed nurses are performing the duties of a certified
277	nursing assistant. Unless otherwise approved by the agency,
278	licensed nurses counted toward the minimum staffing requirements
279	for certified nursing assistants must exclusively perform the
280	duties of a certified nursing assistant for the entire shift and
281	not also be counted toward the minimum staffing requirements for
282	licensed nurses. If the agency approved a facility's request to
283	use a licensed nurse to perform both licensed nursing and
284	certified nursing assistant duties, the facility must allocate
285	the amount of staff time specifically spent on certified nursing
286	assistant duties for the purpose of documenting compliance with
287	minimum staffing requirements for certified and licensed nursing
288	staff. In no event may the hours of a licensed nurse with dual
289	job responsibilities be counted twice.
290	Section 4.  Paragraph (c) of subsection (5) of section
291	409.905, Florida Statutes, is amended to read:
292	409.905  Mandatory Medicaid services.--The agency may make
293	payments for the following services, which are required of the
294	state by Title XIX of the Social Security Act, furnished by
295	Medicaid providers to recipients who are determined to be
296	eligible on the dates on which the services were provided. Any
297	service under this section shall be provided only when medically
298	necessary and in accordance with state and federal law.
299	Mandatory services rendered by providers in mobile units to
300	Medicaid recipients may be restricted by the agency. Nothing in
301	this section shall be construed to prevent or limit the agency
302	from adjusting fees, reimbursement rates, lengths of stay,
303	number of visits, number of services, or any other adjustments
304	necessary to comply with the availability of moneys and any
305	limitations or directions provided for in the General
306	Appropriations Act or chapter 216.
307	(5)  HOSPITAL INPATIENT SERVICES.--The agency shall pay for
308	all covered services provided for the medical care and treatment
309	of a recipient who is admitted as an inpatient by a licensed
310	physician or dentist to a hospital licensed under part I of
311	chapter 395. However, the agency shall limit the payment for
312	inpatient hospital services for a Medicaid recipient 21 years of
313	age or older to 45 days or the number of days necessary to
314	comply with the General Appropriations Act.
315	(c)  For 2 fiscal years beginning July 1, 2008, and ending
316	June 30, 2010, the Agency for Health Care Administration may not
317	shall adjust a hospital's current inpatient per diem rate to
318	reflect the cost of serving the Medicaid population at that
319	institution if:
320	1.  The hospital experiences an increase in Medicaid
321	caseload by more than 25 percent in any year, primarily
322	resulting from the closure of a hospital in the same service
323	area occurring after July 1, 1995;
324	2.  The hospital's Medicaid per diem rate is at least 25
325	percent below the Medicaid per patient cost for that year; or
326	3.  The hospital is located in a county that has five or
327	fewer hospitals, began offering obstetrical services on or after
328	September 1999, and has submitted a request in writing to the
329	agency for a rate adjustment after July 1, 2000, but before
330	September 30, 2000, in which case such hospital's Medicaid
331	inpatient per diem rate shall be adjusted to cost, effective
332	July 1, 2002.
333
334	No later than October 1 of each year, the agency must provide
335	estimated costs for any adjustment in a hospital inpatient per
336	diem pursuant to this paragraph to the Executive Office of the
337	Governor, the House of Representatives General Appropriations
338	Committee, and the Senate Appropriations Committee. Before the
339	agency implements a change in a hospital's inpatient per diem
340	rate pursuant to this paragraph, the Legislature must have
341	specifically appropriated sufficient funds in the General
342	Appropriations Act to support the increase in cost as estimated
343	by the agency.
344	Section 5.  Subsections (7), (14), and (19) of section
345	409.906, Florida Statutes, are amended, and subsection (26) is
346	added to that section, to read:
347	409.906  Optional Medicaid services.--Subject to specific
348	appropriations, the agency may make payments for services which
349	are optional to the state under Title XIX of the Social Security
350	Act and are furnished by Medicaid providers to recipients who
351	are determined to be eligible on the dates on which the services
352	were provided. Any optional service that is provided shall be
353	provided only when medically necessary and in accordance with
354	state and federal law. Optional services rendered by providers
355	in mobile units to Medicaid recipients may be restricted or
356	prohibited by the agency. Nothing in this section shall be
357	construed to prevent or limit the agency from adjusting fees,
358	reimbursement rates, lengths of stay, number of visits, or
359	number of services, or making any other adjustments necessary to
360	comply with the availability of moneys and any limitations or
361	directions provided for in the General Appropriations Act or
362	chapter 216. If necessary to safeguard the state's systems of
363	providing services to elderly and disabled persons and subject
364	to the notice and review provisions of s. 216.177, the Governor
365	may direct the Agency for Health Care Administration to amend
366	the Medicaid state plan to delete the optional Medicaid service
367	known as "Intermediate Care Facilities for the Developmentally
368	Disabled." Optional services may include:
369	(7)  CHIROPRACTIC SERVICES.--For 2 fiscal years beginning
370	July 1, 2008, and ending June 30, 2010, the agency may not pay
371	for chiropractic services. The agency may pay for manual
372	manipulation of the spine and initial services, screening, and X
373	rays provided to a recipient by a licensed chiropractic
374	physician.
375	(14)  HOSPICE CARE SERVICES.--For 2 fiscal years beginning
376	July 1, 2008, and ending June 30, 2010, the agency may not pay
377	for hospice care services. The agency may pay for all reasonable
378	and necessary services for the palliation or management of a
379	recipient's terminal illness, if the services are provided by a
380	hospice that is licensed under part IV of chapter 400 and meets
381	Medicare certification requirements.
382	(19)  PODIATRIC SERVICES.--For 2 fiscal years beginning
383	July 1, 2008, and ending June 30, 2010, the agency may not pay
384	for podiatric services. The agency may pay for services,
385	including diagnosis and medical, surgical, palliative, and
386	mechanical treatment, related to ailments of the human foot and
387	lower leg, if provided to a recipient by a podiatric physician
388	licensed under state law.
389	(26)  ANESTHESIOLOGIST ASSISTANT SERVICES.--The agency may
390	pay for all services provided to a recipient by an
391	anesthesiologist assistant licensed under s. 458.3475 or s.
392	459.023. Reimbursement for such services must be not less than
393	80 percent of the reimbursement that would be paid to a
394	physician who provided the same services.
395	Section 6.  Subsections (13) and (14) of section 409.908,
396	Florida Statutes, as amended by chapter 2007-331, Laws of
397	Florida, are amended, and subsection (23) is added to that
398	section, to read:
399	409.908  Reimbursement of Medicaid providers.--Subject to
400	specific appropriations, the agency shall reimburse Medicaid
401	providers, in accordance with state and federal law, according
402	to methodologies set forth in the rules of the agency and in
403	policy manuals and handbooks incorporated by reference therein.
404	These methodologies may include fee schedules, reimbursement
405	methods based on cost reporting, negotiated fees, competitive
406	bidding pursuant to s. 287.057, and other mechanisms the agency
407	considers efficient and effective for purchasing services or
408	goods on behalf of recipients. If a provider is reimbursed based
409	on cost reporting and submits a cost report late and that cost
410	report would have been used to set a lower reimbursement rate
411	for a rate semester, then the provider's rate for that semester
412	shall be retroactively calculated using the new cost report, and
413	full payment at the recalculated rate shall be effected
414	retroactively. Medicare-granted extensions for filing cost
415	reports, if applicable, shall also apply to Medicaid cost
416	reports. Payment for Medicaid compensable services made on
417	behalf of Medicaid eligible persons is subject to the
418	availability of moneys and any limitations or directions
419	provided for in the General Appropriations Act or chapter 216.
420	Further, nothing in this section shall be construed to prevent
421	or limit the agency from adjusting fees, reimbursement rates,
422	lengths of stay, number of visits, or number of services, or
423	making any other adjustments necessary to comply with the
424	availability of moneys and any limitations or directions
425	provided for in the General Appropriations Act, provided the
426	adjustment is consistent with legislative intent.
427	(13)  Medicare premiums for persons eligible for both
428	Medicare and Medicaid coverage shall be paid at the rates
429	established by Title XVIII of the Social Security Act. For
430	Medicare services rendered to Medicaid-eligible persons,
431	Medicaid shall pay Medicare deductibles and coinsurance as
432	follows:
433	(a)  Medicaid shall make no payment toward deductibles and
434	coinsurance for any service that is not covered by Medicaid.
435	(a)(b)  Medicaid's financial obligation for deductibles and
436	coinsurance payments shall be based on Medicare allowable fees,
437	not on a provider's billed charges.
438	(b)(c)  Medicaid will pay no portion of Medicare
439	deductibles and coinsurance when payment that Medicare has made
440	for the service equals or exceeds what Medicaid would have paid
441	if it had been the sole payor. The combined payment of Medicare
442	and Medicaid shall not exceed the amount Medicaid would have
443	paid had it been the sole payor. The Legislature finds that
444	there has been confusion regarding the reimbursement for
445	services rendered to dually eligible Medicare beneficiaries.
446	Accordingly, the Legislature clarifies that it has always been
447	the intent of the Legislature before and after 1991 that, in
448	reimbursing in accordance with fees established by Title XVIII
449	for premiums, deductibles, and coinsurance for Medicare services
450	rendered by physicians to Medicaid eligible persons, physicians
451	be reimbursed at the lesser of the amount billed by the
452	physician or the Medicaid maximum allowable fee established by
453	the Agency for Health Care Administration, as is permitted by
454	federal law. It has never been the intent of the Legislature
455	with regard to such services rendered by physicians that
456	Medicaid be required to provide any payment for deductibles,
457	coinsurance, or copayments for Medicare cost sharing, or any
458	expenses incurred relating thereto, in excess of the payment
459	amount provided for under the State Medicaid plan for such
460	service. This payment methodology is applicable even in those
461	situations in which the payment for Medicare cost sharing for a
462	qualified Medicare beneficiary with respect to an item or
463	service is reduced or eliminated. This expression of the
464	Legislature is in clarification of existing law and shall apply
465	to payment for, and with respect to provider agreements with
466	respect to, items or services furnished on or after the
467	effective date of this act. This paragraph applies to payment by
468	Medicaid for items and services furnished before the effective
469	date of this act if such payment is the subject of a lawsuit
470	that is based on the provisions of this section, and that is
471	pending as of, or is initiated after, the effective date of this
472	act.
473	(c)(d)  Notwithstanding paragraphs (a) and (b) (a)-(c):
474	1.  Medicaid payments for Nursing Home Medicare part A
475	coinsurance shall be limited to the Medicaid nursing home per
476	diem rate less any amounts paid by Medicare, but only up to the
477	amount of Medicare coinsurance. The Medicaid per diem rate shall
478	be the rate in effect for the dates of service of the crossover
479	claims and may not be subsequently adjusted due to subsequent
480	per diem rate adjustments.
481	2.  Medicaid shall pay all deductibles and coinsurance for
482	Medicare-eligible recipients receiving freestanding end stage
483	renal dialysis center services.
484	3.  Medicaid payments for general hospital inpatient
485	services shall be limited to the Medicare deductible and
486	coinsurance per spell of illness. Medicaid payments for hospital
487	Medicare Part A coinsurance shall be limited to the Medicaid
488	hospital per diem rate less any amounts paid by Medicare, but
489	only up to the amount of Medicare coinsurance. Medicaid payments
490	for coinsurance shall be limited to the Medicaid per diem rate
491	in effect for the dates of service of the crossover claims and
492	may not be subsequently adjusted due to subsequent per diem
493	adjustments. Medicaid shall make no payment toward coinsurance
494	for Medicare general hospital inpatient services.
495	4.  Medicaid shall pay all deductibles and coinsurance for
496	Medicare emergency transportation services provided by
497	ambulances licensed pursuant to chapter 401.
498	(14)  A provider of prescribed drugs shall be reimbursed
499	the least of the amount billed by the provider, the provider's
500	usual and customary charge, or the Medicaid maximum allowable
501	fee established by the agency, plus a dispensing fee. The
502	Medicaid maximum allowable fee for ingredient cost will be based
503	on the lower of: average wholesale price (AWP) minus 16.4 15.4
504	percent, wholesaler acquisition cost (WAC) plus 4.75 5.75
505	percent, the federal upper limit (FUL), the state maximum
506	allowable cost (SMAC), or the usual and customary (UAC) charge
507	billed by the provider. Medicaid providers are required to
508	dispense generic drugs if available at lower cost and the agency
509	has not determined that the branded product is more cost-
510	effective, unless the prescriber has requested and received
511	approval to require the branded product. The agency is directed
512	to implement a variable dispensing fee for payments for
513	prescribed medicines while ensuring continued access for
514	Medicaid recipients. The variable dispensing fee may be based
515	upon, but not limited to, either or both the volume of
516	prescriptions dispensed by a specific pharmacy provider, the
517	volume of prescriptions dispensed to an individual recipient,
518	and dispensing of preferred-drug-list products. The agency may
519	increase the pharmacy dispensing fee authorized by statute and
520	in the annual General Appropriations Act by $0.50 for the
521	dispensing of a Medicaid preferred-drug-list product and reduce
522	the pharmacy dispensing fee by $0.50 for the dispensing of a
523	Medicaid product that is not included on the preferred drug
524	list. The agency may establish a supplemental pharmaceutical
525	dispensing fee to be paid to providers returning unused unit-
526	dose packaged medications to stock and crediting the Medicaid
527	program for the ingredient cost of those medications if the
528	ingredient costs to be credited exceed the value of the
529	supplemental dispensing fee. The agency is authorized to limit
530	reimbursement for prescribed medicine in order to comply with
531	any limitations or directions provided for in the General
532	Appropriations Act, which may include implementing a prospective
533	or concurrent utilization review program.
534	(23)(a)  The agency shall establish rates at a level that
535	ensures no increase in statewide expenditures resulting from a
536	change in unit costs for 2 fiscal years effective July 1, 2008.
537	Reimbursement rates for the 2 fiscal years shall be as provided
538	in the General Appropriations Act.
539	(b)  This subsection applies to the following provider
540	types:
541	1.  Inpatient hospitals.
542	2.  Outpatient hospitals.
543	3.  Nursing homes.
544	4.  County health departments.
545	5.  Community intermediate care facilities for the
546	developmentally disabled.
547
548	The agency shall apply the effect of this subsection to the
549	reimbursement rates for managed care plans and nursing home
550	diversion programs.
551	(c)  The agency shall create a workgroup on hospital
552	reimbursement, a workgroup on nursing facility reimbursement,
553	and a workgroup on managed care plan payment. The workgroups
554	shall evaluate alternative reimbursement and payment
555	methodologies for hospitals, nursing facilities, and managed
556	care plans, including prospective payment methodologies for
557	hospitals and nursing facilities. The nursing facility workgroup
558	shall also consider price-based methodologies for indirect care
559	and acuity adjustments for direct care. The agency shall submit
560	a report on the evaluated alternative reimbursement
561	methodologies to the relevant committees of the Senate and the
562	House of Representatives by November 1, 2009.
563	(d)  This subsection expires June 30, 2010.
564	Section 7.  Paragraph (a) of subsection (2) of section
565	409.911, Florida Statutes, is amended to read:
566	409.911  Disproportionate share program.--Subject to
567	specific allocations established within the General
568	Appropriations Act and any limitations established pursuant to
569	chapter 216, the agency shall distribute, pursuant to this
570	section, moneys to hospitals providing a disproportionate share
571	of Medicaid or charity care services by making quarterly
572	Medicaid payments as required. Notwithstanding the provisions of
573	s. 409.915, counties are exempt from contributing toward the
574	cost of this special reimbursement for hospitals serving a
575	disproportionate share of low-income patients.
576	(2)  The Agency for Health Care Administration shall use
577	the following actual audited data to determine the Medicaid days
578	and charity care to be used in calculating the disproportionate
579	share payment:
580	(a)  The average of the 2002, 2003, and 2004 2000, 2001,
581	and 2002 audited disproportionate share data to determine each
582	hospital's Medicaid days and charity care for the 2008-2009
583	2006-2007 state fiscal year.
584	Section 8.  Section 409.9112, Florida Statutes, is amended
585	to read:
586	409.9112  Disproportionate share program for regional
587	perinatal intensive care centers.--In addition to the payments
588	made under s. 409.911, the Agency for Health Care Administration
589	shall design and implement a system of making disproportionate
590	share payments to those hospitals that participate in the
591	regional perinatal intensive care center program established
592	pursuant to chapter 383. This system of payments shall conform
593	with federal requirements and shall distribute funds in each
594	fiscal year for which an appropriation is made by making
595	quarterly Medicaid payments. Notwithstanding the provisions of
596	s. 409.915, counties are exempt from contributing toward the
597	cost of this special reimbursement for hospitals serving a
598	disproportionate share of low-income patients. For the state
599	fiscal year 2008-2009 2005-2006, the agency shall not distribute
600	moneys under the regional perinatal intensive care centers
601	disproportionate share program.
602	(1)  The following formula shall be used by the agency to
603	calculate the total amount earned for hospitals that participate
604	in the regional perinatal intensive care center program:
605
606	TAE = HDSP/THDSP
607
608	Where:
609	TAE = total amount earned by a regional perinatal intensive
610	care center.
611	HDSP = the prior state fiscal year regional perinatal
612	intensive care center disproportionate share payment to the
613	individual hospital.
614	THDSP = the prior state fiscal year total regional
615	perinatal intensive care center disproportionate share payments
616	to all hospitals.
617	(2)  The total additional payment for hospitals that
618	participate in the regional perinatal intensive care center
619	program shall be calculated by the agency as follows:
620
621	TAP = TAE x TA
622
623	Where:
624	TAP = total additional payment for a regional perinatal
625	intensive care center.
626	TAE = total amount earned by a regional perinatal intensive
627	care center.
628	TA = total appropriation for the regional perinatal
629	intensive care center disproportionate share program.
630	(3)  In order to receive payments under this section, a
631	hospital must be participating in the regional perinatal
632	intensive care center program pursuant to chapter 383 and must
633	meet the following additional requirements:
634	(a)  Agree to conform to all departmental and agency
635	requirements to ensure high quality in the provision of
636	services, including criteria adopted by departmental and agency
637	rule concerning staffing ratios, medical records, standards of
638	care, equipment, space, and such other standards and criteria as
639	the department and agency deem appropriate as specified by rule.
640	(b)  Agree to provide information to the department and
641	agency, in a form and manner to be prescribed by rule of the
642	department and agency, concerning the care provided to all
643	patients in neonatal intensive care centers and high-risk
644	maternity care.
645	(c)  Agree to accept all patients for neonatal intensive
646	care and high-risk maternity care, regardless of ability to pay,
647	on a functional space-available basis.
648	(d)  Agree to develop arrangements with other maternity and
649	neonatal care providers in the hospital's region for the
650	appropriate receipt and transfer of patients in need of
651	specialized maternity and neonatal intensive care services.
652	(e)  Agree to establish and provide a developmental
653	evaluation and services program for certain high-risk neonates,
654	as prescribed and defined by rule of the department.
655	(f)  Agree to sponsor a program of continuing education in
656	perinatal care for health care professionals within the region
657	of the hospital, as specified by rule.
658	(g)  Agree to provide backup and referral services to the
659	department's county health departments and other low-income
660	perinatal providers within the hospital's region, including the
661	development of written agreements between these organizations
662	and the hospital.
663	(h)  Agree to arrange for transportation for high-risk
664	obstetrical patients and neonates in need of transfer from the
665	community to the hospital or from the hospital to another more
666	appropriate facility.
667	(4)  Hospitals which fail to comply with any of the
668	conditions in subsection (3) or the applicable rules of the
669	department and agency shall not receive any payments under this
670	section until full compliance is achieved. A hospital which is
671	not in compliance in two or more consecutive quarters shall not
672	receive its share of the funds. Any forfeited funds shall be
673	distributed by the remaining participating regional perinatal
674	intensive care center program hospitals.
675	Section 9.  Section 409.9113, Florida Statutes, is amended
676	to read:
677	409.9113  Disproportionate share program for teaching
678	hospitals.--In addition to the payments made under ss. 409.911
679	and 409.9112, the Agency for Health Care Administration shall
680	make disproportionate share payments to statutorily defined
681	teaching hospitals for their increased costs associated with
682	medical education programs and for tertiary health care services
683	provided to the indigent. This system of payments shall conform
684	with federal requirements and shall distribute funds in each
685	fiscal year for which an appropriation is made by making
686	quarterly Medicaid payments. Notwithstanding s. 409.915,
687	counties are exempt from contributing toward the cost of this
688	special reimbursement for hospitals serving a disproportionate
689	share of low-income patients. For the state fiscal year 2008-
690	2009 2006-2007, the agency shall distribute the moneys provided
691	in the General Appropriations Act to statutorily defined
692	teaching hospitals and family practice teaching hospitals under
693	the teaching hospital disproportionate share program. The funds
694	provided for statutorily defined teaching hospitals shall be
695	distributed in the same proportion as the state fiscal year
696	2003-2004 teaching hospital disproportionate share funds were
697	distributed or as otherwise provided in the General
698	Appropriations Act. The funds provided for family practice
699	teaching hospitals shall be distributed equally among family
700	practice teaching hospitals.
701	(1)  On or before September 15 of each year, the Agency for
702	Health Care Administration shall calculate an allocation
703	fraction to be used for distributing funds to state statutory
704	teaching hospitals. Subsequent to the end of each quarter of the
705	state fiscal year, the agency shall distribute to each statutory
706	teaching hospital, as defined in s. 408.07, an amount determined
707	by multiplying one-fourth of the funds appropriated for this
708	purpose by the Legislature times such hospital's allocation
709	fraction. The allocation fraction for each such hospital shall
710	be determined by the sum of three primary factors, divided by
711	three. The primary factors are:
712	(a)  The number of nationally accredited graduate medical
713	education programs offered by the hospital, including programs
714	accredited by the Accreditation Council for Graduate Medical
715	Education and the combined Internal Medicine and Pediatrics
716	programs acceptable to both the American Board of Internal
717	Medicine and the American Board of Pediatrics at the beginning
718	of the state fiscal year preceding the date on which the
719	allocation fraction is calculated. The numerical value of this
720	factor is the fraction that the hospital represents of the total
721	number of programs, where the total is computed for all state
722	statutory teaching hospitals.
723	(b)  The number of full-time equivalent trainees in the
724	hospital, which comprises two components:
725	1.  The number of trainees enrolled in nationally
726	accredited graduate medical education programs, as defined in
727	paragraph (a). Full-time equivalents are computed using the
728	fraction of the year during which each trainee is primarily
729	assigned to the given institution, over the state fiscal year
730	preceding the date on which the allocation fraction is
731	calculated. The numerical value of this factor is the fraction
732	that the hospital represents of the total number of full-time
733	equivalent trainees enrolled in accredited graduate programs,
734	where the total is computed for all state statutory teaching
735	hospitals.
736	2.  The number of medical students enrolled in accredited
737	colleges of medicine and engaged in clinical activities,
738	including required clinical clerkships and clinical electives.
739	Full-time equivalents are computed using the fraction of the
740	year during which each trainee is primarily assigned to the
741	given institution, over the course of the state fiscal year
742	preceding the date on which the allocation fraction is
743	calculated. The numerical value of this factor is the fraction
744	that the given hospital represents of the total number of full-
745	time equivalent students enrolled in accredited colleges of
746	medicine, where the total is computed for all state statutory
747	teaching hospitals.
748
749	The primary factor for full-time equivalent trainees is computed
750	as the sum of these two components, divided by two.
751	(c)  A service index that comprises three components:
752	1.  The Agency for Health Care Administration Service
753	Index, computed by applying the standard Service Inventory
754	Scores established by the Agency for Health Care Administration
755	to services offered by the given hospital, as reported on
756	Worksheet A-2 for the last fiscal year reported to the agency
757	before the date on which the allocation fraction is calculated.
758	The numerical value of this factor is the fraction that the
759	given hospital represents of the total Agency for Health Care
760	Administration Service Index values, where the total is computed
761	for all state statutory teaching hospitals.
762	2.  A volume-weighted service index, computed by applying
763	the standard Service Inventory Scores established by the Agency
764	for Health Care Administration to the volume of each service,
765	expressed in terms of the standard units of measure reported on
766	Worksheet A-2 for the last fiscal year reported to the agency
767	before the date on which the allocation factor is calculated.
768	The numerical value of this factor is the fraction that the
769	given hospital represents of the total volume-weighted service
770	index values, where the total is computed for all state
771	statutory teaching hospitals.
772	3.  Total Medicaid payments to each hospital for direct
773	inpatient and outpatient services during the fiscal year
774	preceding the date on which the allocation factor is calculated.
775	This includes payments made to each hospital for such services
776	by Medicaid prepaid health plans, whether the plan was
777	administered by the hospital or not. The numerical value of this
778	factor is the fraction that each hospital represents of the
779	total of such Medicaid payments, where the total is computed for
780	all state statutory teaching hospitals.
781
782	The primary factor for the service index is computed as the sum
783	of these three components, divided by three.
784	(2)  By October 1 of each year, the agency shall use the
785	following formula to calculate the maximum additional
786	disproportionate share payment for statutorily defined teaching
787	hospitals:
788
789	TAP = THAF x A
790
791	Where:
792	TAP = total additional payment.
793	THAF = teaching hospital allocation factor.
794	A = amount appropriated for a teaching hospital
795	disproportionate share program.
796	Section 10.  Section 409.9117, Florida Statutes, is amended
797	to read:
798	409.9117  Primary care disproportionate share program.--For
799	the state fiscal year 2008-2009 2006-2007, the agency shall not
800	distribute moneys under the primary care disproportionate share
801	program.
802	(1)  If federal funds are available for disproportionate
803	share programs in addition to those otherwise provided by law,
804	there shall be created a primary care disproportionate share
805	program.
806	(2)  The following formula shall be used by the agency to
807	calculate the total amount earned for hospitals that participate
808	in the primary care disproportionate share program:
809
810	TAE = HDSP/THDSP
811
812	Where:
813	TAE = total amount earned by a hospital participating in
814	the primary care disproportionate share program.
815	HDSP = the prior state fiscal year primary care
816	disproportionate share payment to the individual hospital.
817	THDSP = the prior state fiscal year total primary care
818	disproportionate share payments to all hospitals.
819	(3)  The total additional payment for hospitals that
820	participate in the primary care disproportionate share program
821	shall be calculated by the agency as follows:
822
823	TAP = TAE x TA
824
825	Where:
826	TAP = total additional payment for a primary care hospital.
827	TAE = total amount earned by a primary care hospital.
828	TA = total appropriation for the primary care
829	disproportionate share program.
830	(4)  In the establishment and funding of this program, the
831	agency shall use the following criteria in addition to those
832	specified in s. 409.911, payments may not be made to a hospital
833	unless the hospital agrees to:
834	(a)  Cooperate with a Medicaid prepaid health plan, if one
835	exists in the community.
836	(b)  Ensure the availability of primary and specialty care
837	physicians to Medicaid recipients who are not enrolled in a
838	prepaid capitated arrangement and who are in need of access to
839	such physicians.
840	(c)  Coordinate and provide primary care services free of
841	charge, except copayments, to all persons with incomes up to 100
842	percent of the federal poverty level who are not otherwise
843	covered by Medicaid or another program administered by a
844	governmental entity, and to provide such services based on a
845	sliding fee scale to all persons with incomes up to 200 percent
846	of the federal poverty level who are not otherwise covered by
847	Medicaid or another program administered by a governmental
848	entity, except that eligibility may be limited to persons who
849	reside within a more limited area, as agreed to by the agency
850	and the hospital.
851	(d)  Contract with any federally qualified health center,
852	if one exists within the agreed geopolitical boundaries,
853	concerning the provision of primary care services, in order to
854	guarantee delivery of services in a nonduplicative fashion, and
855	to provide for referral arrangements, privileges, and
856	admissions, as appropriate. The hospital shall agree to provide
857	at an onsite or offsite facility primary care services within 24
858	hours to which all Medicaid recipients and persons eligible
859	under this paragraph who do not require emergency room services
860	are referred during normal daylight hours.
861	(e)  Cooperate with the agency, the county, and other
862	entities to ensure the provision of certain public health
863	services, case management, referral and acceptance of patients,
864	and sharing of epidemiological data, as the agency and the
865	hospital find mutually necessary and desirable to promote and
866	protect the public health within the agreed geopolitical
867	boundaries.
868	(f)  In cooperation with the county in which the hospital
869	resides, develop a low-cost, outpatient, prepaid health care
870	program to persons who are not eligible for the Medicaid
871	program, and who reside within the area.
872	(g)  Provide inpatient services to residents within the
873	area who are not eligible for Medicaid or Medicare, and who do
874	not have private health insurance, regardless of ability to pay,
875	on the basis of available space, except that nothing shall
876	prevent the hospital from establishing bill collection programs
877	based on ability to pay.
878	(h)  Work with the Florida Healthy Kids Corporation, the
879	Florida Health Care Purchasing Cooperative, and business health
880	coalitions, as appropriate, to develop a feasibility study and
881	plan to provide a low-cost comprehensive health insurance plan
882	to persons who reside within the area and who do not have access
883	to such a plan.
884	(i)  Work with public health officials and other experts to
885	provide community health education and prevention activities
886	designed to promote healthy lifestyles and appropriate use of
887	health services.
888	(j)  Work with the local health council to develop a plan
889	for promoting access to affordable health care services for all
890	persons who reside within the area, including, but not limited
891	to, public health services, primary care services, inpatient
892	services, and affordable health insurance generally.
893
894	Any hospital that fails to comply with any of the provisions of
895	this subsection, or any other contractual condition, may not
896	receive payments under this section until full compliance is
897	achieved.
898	Section 11.  Paragraph (b) of subsection (4) and paragraph
899	(a) of subsection (39) of section 409.912, Florida Statutes, are
900	amended, and subsection (53) is added to that section, to read:
901	409.912  Cost-effective purchasing of health care.--The
902	agency shall purchase goods and services for Medicaid recipients
903	in the most cost-effective manner consistent with the delivery
904	of quality medical care. To ensure that medical services are
905	effectively utilized, the agency may, in any case, require a
906	confirmation or second physician's opinion of the correct
907	diagnosis for purposes of authorizing future services under the
908	Medicaid program. This section does not restrict access to
909	emergency services or poststabilization care services as defined
910	in 42 C.F.R. part 438.114. Such confirmation or second opinion
911	shall be rendered in a manner approved by the agency. The agency
912	shall maximize the use of prepaid per capita and prepaid
913	aggregate fixed-sum basis services when appropriate and other
914	alternative service delivery and reimbursement methodologies,
915	including competitive bidding pursuant to s. 287.057, designed
916	to facilitate the cost-effective purchase of a case-managed
917	continuum of care. The agency shall also require providers to
918	minimize the exposure of recipients to the need for acute
919	inpatient, custodial, and other institutional care and the
920	inappropriate or unnecessary use of high-cost services. The
921	agency shall contract with a vendor to monitor and evaluate the
922	clinical practice patterns of providers in order to identify
923	trends that are outside the normal practice patterns of a
924	provider's professional peers or the national guidelines of a
925	provider's professional association. The vendor must be able to
926	provide information and counseling to a provider whose practice
927	patterns are outside the norms, in consultation with the agency,
928	to improve patient care and reduce inappropriate utilization.
929	The agency may mandate prior authorization, drug therapy
930	management, or disease management participation for certain
931	populations of Medicaid beneficiaries, certain drug classes, or
932	particular drugs to prevent fraud, abuse, overuse, and possible
933	dangerous drug interactions. The Pharmaceutical and Therapeutics
934	Committee shall make recommendations to the agency on drugs for
935	which prior authorization is required. The agency shall inform
936	the Pharmaceutical and Therapeutics Committee of its decisions
937	regarding drugs subject to prior authorization. The agency is
938	authorized to limit the entities it contracts with or enrolls as
939	Medicaid providers by developing a provider network through
940	provider credentialing. The agency may competitively bid single-
941	source-provider contracts if procurement of goods or services
942	results in demonstrated cost savings to the state without
943	limiting access to care. The agency may limit its network based
944	on the assessment of beneficiary access to care, provider
945	availability, provider quality standards, time and distance
946	standards for access to care, the cultural competence of the
947	provider network, demographic characteristics of Medicaid
948	beneficiaries, practice and provider-to-beneficiary standards,
949	appointment wait times, beneficiary use of services, provider
950	turnover, provider profiling, provider licensure history,
951	previous program integrity investigations and findings, peer
952	review, provider Medicaid policy and billing compliance records,
953	clinical and medical record audits, and other factors. Providers
954	shall not be entitled to enrollment in the Medicaid provider
955	network. The agency shall determine instances in which allowing
956	Medicaid beneficiaries to purchase durable medical equipment and
957	other goods is less expensive to the Medicaid program than long-
958	term rental of the equipment or goods. The agency may establish
959	rules to facilitate purchases in lieu of long-term rentals in
960	order to protect against fraud and abuse in the Medicaid program
961	as defined in s. 409.913. The agency may seek federal waivers
962	necessary to administer these policies.
963	(4)  The agency may contract with:
964	(b)  An entity that is providing comprehensive behavioral
965	health care services to certain Medicaid recipients through a
966	capitated, prepaid arrangement pursuant to the federal waiver
967	provided for by s. 409.905(5). Such an entity must be licensed
968	under chapter 624, chapter 636, or chapter 641 and must possess
969	the clinical systems and operational competence to manage risk
970	and provide comprehensive behavioral health care to Medicaid
971	recipients. As used in this paragraph, the term "comprehensive
972	behavioral health care services" means covered mental health and
973	substance abuse treatment services that are available to
974	Medicaid recipients. The secretary of the Department of Children
975	and Family Services shall approve provisions of procurements
976	related to children in the department's care or custody prior to
977	enrolling such children in a prepaid behavioral health plan. Any
978	contract awarded under this paragraph must be competitively
979	procured. In developing the behavioral health care prepaid plan
980	procurement document, the agency shall ensure that the
981	procurement document requires the contractor to develop and
982	implement a plan to ensure compliance with s. 394.4574 related
983	to services provided to residents of licensed assisted living
984	facilities that hold a limited mental health license. Except as
985	provided in subparagraph 8., and except in counties where the
986	Medicaid managed care pilot program is authorized pursuant to s.
987	409.91211, the agency shall seek federal approval to contract
988	with a single entity meeting these requirements to provide
989	comprehensive behavioral health care services to all Medicaid
990	recipients not enrolled in a Medicaid managed care plan
991	authorized under s. 409.91211 or a Medicaid health maintenance
992	organization in an AHCA area. In an AHCA area where the Medicaid
993	managed care pilot program is authorized pursuant to s.
994	409.91211 in one or more counties, the agency may procure a
995	contract with a single entity to serve the remaining counties as
996	an AHCA area or the remaining counties may be included with an
997	adjacent AHCA area and shall be subject to this paragraph. Each
998	entity must offer sufficient choice of providers in its network
999	to ensure recipient access to care and the opportunity to select
1000	a provider with whom they are satisfied. The network shall
1001	include all public mental health hospitals. To ensure unimpaired
1002	access to behavioral health care services by Medicaid
1003	recipients, all contracts issued pursuant to this paragraph
1004	shall require 80 percent of the capitation paid to the managed
1005	care plan, including health maintenance organizations, to be
1006	expended for the provision of behavioral health care services.
1007	In the event the managed care plan expends less than 80 percent
1008	of the capitation paid pursuant to this paragraph for the
1009	provision of behavioral health care services, the difference
1010	shall be returned to the agency. The agency shall provide the
1011	managed care plan with a certification letter indicating the
1012	amount of capitation paid during each calendar year for the
1013	provision of behavioral health care services pursuant to this
1014	section. The agency may reimburse for substance abuse treatment
1015	services on a fee-for-service basis until the agency finds that
1016	adequate funds are available for capitated, prepaid
1017	arrangements.
1018	1.  By January 1, 2001, the agency shall modify the
1019	contracts with the entities providing comprehensive inpatient
1020	and outpatient mental health care services to Medicaid
1021	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
1022	Counties, to include substance abuse treatment services.
1023	2.  By July 1, 2003, the agency and the Department of
1024	Children and Family Services shall execute a written agreement
1025	that requires collaboration and joint development of all policy,
1026	budgets, procurement documents, contracts, and monitoring plans
1027	that have an impact on the state and Medicaid community mental
1028	health and targeted case management programs.
1029	3.  Except as provided in subparagraph 8., by July 1, 2006,
1030	the agency and the Department of Children and Family Services
1031	shall contract with managed care entities in each AHCA area
1032	except area 6 or arrange to provide comprehensive inpatient and
1033	outpatient mental health and substance abuse services through
1034	capitated prepaid arrangements to all Medicaid recipients who
1035	are eligible to participate in such plans under federal law and
1036	regulation. In AHCA areas where eligible individuals number less
1037	than 150,000, the agency shall contract with a single managed
1038	care plan to provide comprehensive behavioral health services to
1039	all recipients who are not enrolled in a Medicaid health
1040	maintenance organization or a Medicaid capitated managed care
1041	plan authorized under s. 409.91211. The agency may contract with
1042	more than one comprehensive behavioral health provider to
1043	provide care to recipients who are not enrolled in a Medicaid
1044	capitated managed care plan authorized under s. 409.91211 or a
1045	Medicaid health maintenance organization in AHCA areas where the
1046	eligible population exceeds 150,000. In an AHCA area where the
1047	Medicaid managed care pilot program is authorized pursuant to s.
1048	409.91211 in one or more counties, the agency may procure a
1049	contract with a single entity to serve the remaining counties as
1050	an AHCA area or the remaining counties may be included with an
1051	adjacent AHCA area and shall be subject to this paragraph.
1052	Contracts for comprehensive behavioral health providers awarded
1053	pursuant to this section shall be competitively procured. Both
1054	for-profit and not-for-profit corporations shall be eligible to
1055	compete. Managed care plans contracting with the agency under
1056	subsection (3) shall provide and receive payment for the same
1057	comprehensive behavioral health benefits as provided in AHCA
1058	rules, including handbooks incorporated by reference. In AHCA
1059	area 11, the agency shall contract with at least two
1060	comprehensive behavioral health care providers to provide
1061	behavioral health care to recipients in that area who are
1062	enrolled in, or assigned to, the MediPass program. One of the
1063	behavioral health care contracts shall be with the existing
1064	provider service network pilot project, as described in
1065	paragraph (d), for the purpose of demonstrating the cost-
1066	effectiveness of the provision of quality mental health services
1067	through a public hospital-operated managed care model. Payment
1068	shall be at an agreed-upon capitated rate to ensure cost
1069	savings. Of the recipients in area 11 who are assigned to
1070	MediPass under the provisions of s. 409.9122(2)(k), a minimum of
1071	50,000 of those MediPass-enrolled recipients shall be assigned
1072	to the existing provider service network in area 11 for their
1073	behavioral care.
1074	4.  By October 1, 2003, the agency and the department shall
1075	submit a plan to the Governor, the President of the Senate, and
1076	the Speaker of the House of Representatives which provides for
1077	the full implementation of capitated prepaid behavioral health
1078	care in all areas of the state.
1079	a.  Implementation shall begin in 2003 in those AHCA areas
1080	of the state where the agency is able to establish sufficient
1081	capitation rates.
1082	b.  If the agency determines that the proposed capitation
1083	rate in any area is insufficient to provide appropriate
1084	services, the agency may adjust the capitation rate to ensure
1085	that care will be available. The agency and the department may
1086	use existing general revenue to address any additional required
1087	match but may not over-obligate existing funds on an annualized
1088	basis.
1089	c.  Subject to any limitations provided for in the General
1090	Appropriations Act, the agency, in compliance with appropriate
1091	federal authorization, shall develop policies and procedures
1092	that allow for certification of local and state funds.
1093	5.  Children residing in a statewide inpatient psychiatric
1094	program, or in a Department of Juvenile Justice or a Department
1095	of Children and Family Services residential program approved as
1096	a Medicaid behavioral health overlay services provider shall not
1097	be included in a behavioral health care prepaid health plan or
1098	any other Medicaid managed care plan pursuant to this paragraph.
1099	6.  In converting to a prepaid system of delivery, the
1100	agency shall in its procurement document require an entity
1101	providing only comprehensive behavioral health care services to
1102	prevent the displacement of indigent care patients by enrollees
1103	in the Medicaid prepaid health plan providing behavioral health
1104	care services from facilities receiving state funding to provide
1105	indigent behavioral health care, to facilities licensed under
1106	chapter 395 which do not receive state funding for indigent
1107	behavioral health care, or reimburse the unsubsidized facility
1108	for the cost of behavioral health care provided to the displaced
1109	indigent care patient.
1110	7.  Traditional community mental health providers under
1111	contract with the Department of Children and Family Services
1112	pursuant to part IV of chapter 394, child welfare providers
1113	under contract with the Department of Children and Family
1114	Services in areas 1 and 6, and inpatient mental health providers
1115	licensed pursuant to chapter 395 must be offered an opportunity
1116	to accept or decline a contract to participate in any provider
1117	network for prepaid behavioral health services.
1118	8.  All Medicaid-eligible children, except children in area
1119	1 and children in Highlands, Hardee, Polk, or Manatee Counties
1120	of area 6 For fiscal year 2004-2005, all Medicaid eligible
1121	children, except children in areas 1 and 6, whose cases are open
1122	for child welfare services in the HomeSafeNet system, shall be
1123	enrolled in MediPass or in Medicaid fee-for-service and all
1124	their behavioral health care services including inpatient,
1125	outpatient psychiatric, community mental health, and case
1126	management shall be reimbursed on a fee-for-service basis.
1127	Beginning July 1, 2005, such children, who are open for child
1128	welfare services in the HomeSafeNet system, shall receive their
1129	behavioral health care services through a specialty prepaid plan
1130	operated by community-based lead agencies either through a
1131	single agency or formal agreements among several agencies. The
1132	specialty prepaid plan must result in savings to the state
1133	comparable to savings achieved in other Medicaid managed care
1134	and prepaid programs. Such plan must provide mechanisms to
1135	maximize state and local revenues. The specialty prepaid plan
1136	shall be developed by the agency and the Department of Children
1137	and Family Services. The agency is authorized to seek any
1138	federal waivers to implement this initiative. Medicaid-eligible
1139	children whose cases are open for child welfare services in the
1140	HomeSafeNet system and who reside in AHCA area 10 are exempt
1141	from the specialty prepaid plan upon the development of a
1142	service delivery mechanism for children who reside in area 10 as
1143	specified in s. 409.91211(3)(dd).
1144	(39)(a)  The agency shall implement a Medicaid prescribed-
1145	drug spending-control program that includes the following
1146	components:
1147	1.  A Medicaid preferred drug list, which shall be a
1148	listing of cost-effective therapeutic options recommended by the
1149	Medicaid Pharmacy and Therapeutics Committee established
1150	pursuant to s. 409.91195 and adopted by the agency for each
1151	therapeutic class on the preferred drug list. At the discretion
1152	of the committee, and when feasible, the preferred drug list
1153	should include at least two products in a therapeutic class. The
1154	agency may post the preferred drug list and updates to the
1155	preferred drug list on an Internet website without following the
1156	rulemaking procedures of chapter 120. Antiretroviral agents are
1157	excluded from the preferred drug list. The agency shall also
1158	limit the amount of a prescribed drug dispensed to no more than
1159	a 34-day supply unless the drug products' smallest marketed
1160	package is greater than a 34-day supply, or the drug is
1161	determined by the agency to be a maintenance drug in which case
1162	a 100-day maximum supply may be authorized. The agency is
1163	authorized to seek any federal waivers necessary to implement
1164	these cost-control programs and to continue participation in the
1165	federal Medicaid rebate program, or alternatively to negotiate
1166	state-only manufacturer rebates. The agency may adopt rules to
1167	implement this subparagraph. The agency shall continue to
1168	provide unlimited contraceptive drugs and items. The agency must
1169	establish procedures to ensure that:
1170	a.  There will be a response to a request for prior
1171	consultation by telephone or other telecommunication device
1172	within 24 hours after receipt of a request for prior
1173	consultation; and
1174	b.  A 72-hour supply of the drug prescribed will be
1175	provided in an emergency or when the agency does not provide a
1176	response within 24 hours as required by sub-subparagraph a.
1177	2.  Reimbursement to pharmacies for Medicaid prescribed
1178	drugs shall be set at the lesser of: the average wholesale price
1179	(AWP) minus 16.4 15.4 percent, the wholesaler acquisition cost
1180	(WAC) plus 4.75 5.75 percent, the federal upper limit (FUL), the
1181	state maximum allowable cost (SMAC), or the usual and customary
1182	(UAC) charge billed by the provider.
1183	3.  The agency shall develop and implement a process for
1184	managing the drug therapies of Medicaid recipients who are using
1185	significant numbers of prescribed drugs each month. The
1186	management process may include, but is not limited to,
1187	comprehensive, physician-directed medical-record reviews, claims
1188	analyses, and case evaluations to determine the medical
1189	necessity and appropriateness of a patient's treatment plan and
1190	drug therapies. The agency may contract with a private
1191	organization to provide drug-program-management services. The
1192	Medicaid drug benefit management program shall include
1193	initiatives to manage drug therapies for HIV/AIDS patients,
1194	patients using 20 or more unique prescriptions in a 180-day
1195	period, and the top 1,000 patients in annual spending. The
1196	agency shall enroll any Medicaid recipient in the drug benefit
1197	management program if he or she meets the specifications of this
1198	provision and is not enrolled in a Medicaid health maintenance
1199	organization.
1200	4.  The agency may limit the size of its pharmacy network
1201	based on need, competitive bidding, price negotiations,
1202	credentialing, or similar criteria. The agency shall give
1203	special consideration to rural areas in determining the size and
1204	location of pharmacies included in the Medicaid pharmacy
1205	network. A pharmacy credentialing process may include criteria
1206	such as a pharmacy's full-service status, location, size,
1207	patient educational programs, patient consultation, disease
1208	management services, and other characteristics. The agency may
1209	impose a moratorium on Medicaid pharmacy enrollment when it is
1210	determined that it has a sufficient number of Medicaid-
1211	participating providers. The agency must allow dispensing
1212	practitioners to participate as a part of the Medicaid pharmacy
1213	network regardless of the practitioner's proximity to any other
1214	entity that is dispensing prescription drugs under the Medicaid
1215	program. A dispensing practitioner must meet all credentialing
1216	requirements applicable to his or her practice, as determined by
1217	the agency.
1218	5.  The agency shall develop and implement a program that
1219	requires Medicaid practitioners who prescribe drugs to use a
1220	counterfeit-proof prescription pad for Medicaid prescriptions.
1221	The agency shall require the use of standardized counterfeit-
1222	proof prescription pads by Medicaid-participating prescribers or
1223	prescribers who write prescriptions for Medicaid recipients. The
1224	agency may implement the program in targeted geographic areas or
1225	statewide.
1226	6.  The agency may enter into arrangements that require
1227	manufacturers of generic drugs prescribed to Medicaid recipients
1228	to provide rebates of at least 15.1 percent of the average
1229	manufacturer price for the manufacturer's generic products.
1230	These arrangements shall require that if a generic-drug
1231	manufacturer pays federal rebates for Medicaid-reimbursed drugs
1232	at a level below 15.1 percent, the manufacturer must provide a
1233	supplemental rebate to the state in an amount necessary to
1234	achieve a 15.1-percent rebate level.
1235	7.  The agency may establish a preferred drug list as
1236	described in this subsection, and, pursuant to the establishment
1237	of such preferred drug list, it is authorized to negotiate
1238	supplemental rebates from manufacturers that are in addition to
1239	those required by Title XIX of the Social Security Act and at no
1240	less than 14 percent of the average manufacturer price as
1241	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
1242	the federal or supplemental rebate, or both, equals or exceeds
1243	29 percent. There is no upper limit on the supplemental rebates
1244	the agency may negotiate. The agency may determine that specific
1245	products, brand-name or generic, are competitive at lower rebate
1246	percentages. Agreement to pay the minimum supplemental rebate
1247	percentage will guarantee a manufacturer that the Medicaid
1248	Pharmaceutical and Therapeutics Committee will consider a
1249	product for inclusion on the preferred drug list. However, a
1250	pharmaceutical manufacturer is not guaranteed placement on the
1251	preferred drug list by simply paying the minimum supplemental
1252	rebate. Agency decisions will be made on the clinical efficacy
1253	of a drug and recommendations of the Medicaid Pharmaceutical and
1254	Therapeutics Committee, as well as the price of competing
1255	products minus federal and state rebates. The agency is
1256	authorized to contract with an outside agency or contractor to
1257	conduct negotiations for supplemental rebates. For the purposes
1258	of this section, the term "supplemental rebates" means cash
1259	rebates. Effective July 1, 2004, value-added programs as a
1260	substitution for supplemental rebates are prohibited. The agency
1261	is authorized to seek any federal waivers to implement this
1262	initiative.
1263	8.  The Agency for Health Care Administration shall expand
1264	home delivery of pharmacy products. To assist Medicaid patients
1265	in securing their prescriptions and reduce program costs, the
1266	agency shall expand its current mail-order-pharmacy diabetes-
1267	supply program to include all generic and brand-name drugs used
1268	by Medicaid patients with diabetes. Medicaid recipients in the
1269	current program may obtain nondiabetes drugs on a voluntary
1270	basis. This initiative is limited to the geographic area covered
1271	by the current contract. The agency may seek and implement any
1272	federal waivers necessary to implement this subparagraph.
1273	9.  The agency shall limit to one dose per month any drug
1274	prescribed to treat erectile dysfunction.
1275	10.a.  The agency may implement a Medicaid behavioral drug
1276	management system. The agency may contract with a vendor that
1277	has experience in operating behavioral drug management systems
1278	to implement this program. The agency is authorized to seek
1279	federal waivers to implement this program.
1280	b.  The agency, in conjunction with the Department of
1281	Children and Family Services, may implement the Medicaid
1282	behavioral drug management system that is designed to improve
1283	the quality of care and behavioral health prescribing practices
1284	based on best practice guidelines, improve patient adherence to
1285	medication plans, reduce clinical risk, and lower prescribed
1286	drug costs and the rate of inappropriate spending on Medicaid
1287	behavioral drugs. The program may include the following
1288	elements:
1289	(I)  Provide for the development and adoption of best
1290	practice guidelines for behavioral health-related drugs such as
1291	antipsychotics, antidepressants, and medications for treating
1292	bipolar disorders and other behavioral conditions; translate
1293	them into practice; review behavioral health prescribers and
1294	compare their prescribing patterns to a number of indicators
1295	that are based on national standards; and determine deviations
1296	from best practice guidelines.
1297	(II)  Implement processes for providing feedback to and
1298	educating prescribers using best practice educational materials
1299	and peer-to-peer consultation.
1300	(III)  Assess Medicaid beneficiaries who are outliers in
1301	their use of behavioral health drugs with regard to the numbers
1302	and types of drugs taken, drug dosages, combination drug
1303	therapies, and other indicators of improper use of behavioral
1304	health drugs.
1305	(IV)  Alert prescribers to patients who fail to refill
1306	prescriptions in a timely fashion, are prescribed multiple same-
1307	class behavioral health drugs, and may have other potential
1308	medication problems.
1309	(V)  Track spending trends for behavioral health drugs and
1310	deviation from best practice guidelines.
1311	(VI)  Use educational and technological approaches to
1312	promote best practices, educate consumers, and train prescribers
1313	in the use of practice guidelines.
1314	(VII)  Disseminate electronic and published materials.
1315	(VIII)  Hold statewide and regional conferences.
1316	(IX)  Implement a disease management program with a model
1317	quality-based medication component for severely mentally ill
1318	individuals and emotionally disturbed children who are high
1319	users of care.
1320	11.a.  The agency shall implement a Medicaid prescription
1321	drug management system. The agency may contract with a vendor
1322	that has experience in operating prescription drug management
1323	systems in order to implement this system. Any management system
1324	that is implemented in accordance with this subparagraph must
1325	rely on cooperation between physicians and pharmacists to
1326	determine appropriate practice patterns and clinical guidelines
1327	to improve the prescribing, dispensing, and use of drugs in the
1328	Medicaid program. The agency may seek federal waivers to
1329	implement this program.
1330	b.  The drug management system must be designed to improve
1331	the quality of care and prescribing practices based on best
1332	practice guidelines, improve patient adherence to medication
1333	plans, reduce clinical risk, and lower prescribed drug costs and
1334	the rate of inappropriate spending on Medicaid prescription
1335	drugs. The program must:
1336	(I)  Provide for the development and adoption of best
1337	practice guidelines for the prescribing and use of drugs in the
1338	Medicaid program, including translating best practice guidelines
1339	into practice; reviewing prescriber patterns and comparing them
1340	to indicators that are based on national standards and practice
1341	patterns of clinical peers in their community, statewide, and
1342	nationally; and determine deviations from best practice
1343	guidelines.
1344	(II)  Implement processes for providing feedback to and
1345	educating prescribers using best practice educational materials
1346	and peer-to-peer consultation.
1347	(III)  Assess Medicaid recipients who are outliers in their
1348	use of a single or multiple prescription drugs with regard to
1349	the numbers and types of drugs taken, drug dosages, combination
1350	drug therapies, and other indicators of improper use of
1351	prescription drugs.
1352	(IV)  Alert prescribers to patients who fail to refill
1353	prescriptions in a timely fashion, are prescribed multiple drugs
1354	that may be redundant or contraindicated, or may have other
1355	potential medication problems.
1356	(V)  Track spending trends for prescription drugs and
1357	deviation from best practice guidelines.
1358	(VI)  Use educational and technological approaches to
1359	promote best practices, educate consumers, and train prescribers
1360	in the use of practice guidelines.
1361	(VII)  Disseminate electronic and published materials.
1362	(VIII)  Hold statewide and regional conferences.
1363	(IX)  Implement disease management programs in cooperation
1364	with physicians and pharmacists, along with a model quality-
1365	based medication component for individuals having chronic
1366	medical conditions.
1367	12.  The agency is authorized to contract for drug rebate
1368	administration, including, but not limited to, calculating
1369	rebate amounts, invoicing manufacturers, negotiating disputes
1370	with manufacturers, and maintaining a database of rebate
1371	collections.
1372	13.  The agency may specify the preferred daily dosing form
1373	or strength for the purpose of promoting best practices with
1374	regard to the prescribing of certain drugs as specified in the
1375	General Appropriations Act and ensuring cost-effective
1376	prescribing practices.
1377	14.  The agency may require prior authorization for
1378	Medicaid-covered prescribed drugs. The agency may, but is not
1379	required to, prior-authorize the use of a product:
1380	a.  For an indication not approved in labeling;
1381	b.  To comply with certain clinical guidelines; or
1382	c.  If the product has the potential for overuse, misuse,
1383	or abuse.
1384
1385	The agency may require the prescribing professional to provide
1386	information about the rationale and supporting medical evidence
1387	for the use of a drug. The agency may post prior authorization
1388	criteria and protocol and updates to the list of drugs that are
1389	subject to prior authorization on an Internet website without
1390	amending its rule or engaging in additional rulemaking.
1391	15.  The agency, in conjunction with the Pharmaceutical and
1392	Therapeutics Committee, may require age-related prior
1393	authorizations for certain prescribed drugs. The agency may
1394	preauthorize the use of a drug for a recipient who may not meet
1395	the age requirement or may exceed the length of therapy for use
1396	of this product as recommended by the manufacturer and approved
1397	by the Food and Drug Administration. Prior authorization may
1398	require the prescribing professional to provide information
1399	about the rationale and supporting medical evidence for the use
1400	of a drug.
1401	16.  The agency shall implement a step-therapy prior
1402	authorization approval process for medications excluded from the
1403	preferred drug list. Medications listed on the preferred drug
1404	list must be used within the previous 12 months prior to the
1405	alternative medications that are not listed. The step-therapy
1406	prior authorization may require the prescriber to use the
1407	medications of a similar drug class or for a similar medical
1408	indication unless contraindicated in the Food and Drug
1409	Administration labeling. The trial period between the specified
1410	steps may vary according to the medical indication. The step-
1411	therapy approval process shall be developed in accordance with
1412	the committee as stated in s. 409.91195(7) and (8). A drug
1413	product may be approved without meeting the step-therapy prior
1414	authorization criteria if the prescribing physician provides the
1415	agency with additional written medical or clinical documentation
1416	that the product is medically necessary because:
1417	a.  There is not a drug on the preferred drug list to treat
1418	the disease or medical condition which is an acceptable clinical
1419	alternative;
1420	b.  The alternatives have been ineffective in the treatment
1421	of the beneficiary's disease; or
1422	c.  Based on historic evidence and known characteristics of
1423	the patient and the drug, the drug is likely to be ineffective,
1424	or the number of doses have been ineffective.
1425
1426	The agency shall work with the physician to determine the best
1427	alternative for the patient. The agency may adopt rules waiving
1428	the requirements for written clinical documentation for specific
1429	drugs in limited clinical situations.
1430	17.  The agency shall implement a return and reuse program
1431	for drugs dispensed by pharmacies to institutional recipients,
1432	which includes payment of a $5 restocking fee for the
1433	implementation and operation of the program. The return and
1434	reuse program shall be implemented electronically and in a
1435	manner that promotes efficiency. The program must permit a
1436	pharmacy to exclude drugs from the program if it is not
1437	practical or cost-effective for the drug to be included and must
1438	provide for the return to inventory of drugs that cannot be
1439	credited or returned in a cost-effective manner. The agency
1440	shall determine if the program has reduced the amount of
1441	Medicaid prescription drugs which are destroyed on an annual
1442	basis and if there are additional ways to ensure more
1443	prescription drugs are not destroyed which could safely be
1444	reused. The agency's conclusion and recommendations shall be
1445	reported to the Legislature by December 1, 2005.
1446	(53)  Before seeking an amendment to the state plan for
1447	purposes of implementing programs authorized by the Deficit
1448	Reduction Act of 2005, the agency shall notify the Legislature.
1449	Section 12.  Section 409.91206, Florida Statutes, is
1450	created to read:
1451	409.91206  Alternatives for health and long-term care
1452	reforms.--The Governor, the President of the Senate, and the
1453	Speaker of the House of Representatives may convene workgroups
1454	to propose alternatives for cost-effective health and long-term
1455	care reforms, including, but not limited to, reforms for
1456	Medicaid.
1457	Section 13.  Section 409.91211, Florida Statutes, as
1458	amended by chapter 2007-331, Laws of Florida, is amended to
1459	read:
1460	409.91211  Medicaid managed care pilot program.--
1461	(1)(a)  The agency is authorized to seek and implement
1462	experimental, pilot, or demonstration project waivers, pursuant
1463	to s. 1115 of the Social Security Act, to create a statewide
1464	initiative to provide for a more efficient and effective service
1465	delivery system that enhances quality of care and client
1466	outcomes in the Florida Medicaid program pursuant to this
1467	section. Phase one of the demonstration shall be implemented in
1468	two geographic areas. One demonstration site shall include only
1469	Broward County. A second demonstration site shall initially
1470	include Duval County and shall be expanded to include Baker,
1471	Clay, and Nassau Counties within 1 year after the Duval County
1472	program becomes operational. A third demonstration site shall
1473	include Hardee, Highlands, Hillsborough, Manatee, Miami-Dade,
1474	Monroe, Pasco, Pinellas, and Polk Counties. The agency shall
1475	begin enrolling recipients in the third demonstration site by
1476	September 1, 2010. The agency shall implement expansion of the
1477	program to include the remaining counties of the state and
1478	remaining eligibility groups in accordance with the process
1479	specified in the federally approved special terms and conditions
1480	numbered 11-W-00206/4, as approved by the federal Centers for
1481	Medicare and Medicaid Services on October 19, 2005, with a goal
1482	of full statewide implementation by June 30, 2011.
1483	(b)  This waiver authority is contingent upon federal
1484	approval to preserve the upper-payment-limit funding mechanism
1485	for hospitals, including a guarantee of a reasonable growth
1486	factor, a methodology to allow the use of a portion of these
1487	funds to serve as a risk pool for demonstration sites,
1488	provisions to preserve the state's ability to use
1489	intergovernmental transfers, and provisions to protect the
1490	disproportionate share program authorized pursuant to this
1491	chapter. Upon completion of the evaluation conducted under s. 3,
1492	ch. 2005-133, Laws of Florida, the agency may request statewide
1493	expansion of the demonstration projects. Statewide phase-in to
1494	additional counties shall be contingent upon review and approval
1495	by the Legislature. Under the upper-payment-limit program, or
1496	the low-income pool as implemented by the Agency for Health Care
1497	Administration pursuant to federal waiver, the state matching
1498	funds required for the program shall be provided by local
1499	governmental entities through intergovernmental transfers in
1500	accordance with published federal statutes and regulations. The
1501	Agency for Health Care Administration shall distribute upper-
1502	payment-limit, disproportionate share hospital, and low-income
1503	pool funds according to published federal statutes, regulations,
1504	and waivers and the low-income pool methodology approved by the
1505	federal Centers for Medicare and Medicaid Services.
1506	(c)  It is the intent of the Legislature that the low-
1507	income pool plan required by the terms and conditions of the
1508	Medicaid reform waiver and submitted to the federal Centers for
1509	Medicare and Medicaid Services propose the distribution of the
1510	above-mentioned program funds based on the following objectives:
1511	1.  Assure a broad and fair distribution of available funds
1512	based on the access provided by Medicaid participating
1513	hospitals, regardless of their ownership status, through their
1514	delivery of inpatient or outpatient care for Medicaid
1515	beneficiaries and uninsured and underinsured individuals;
1516	2.  Assure accessible emergency inpatient and outpatient
1517	care for Medicaid beneficiaries and uninsured and underinsured
1518	individuals;
1519	3.  Enhance primary, preventive, and other ambulatory care
1520	coverages for uninsured individuals;
1521	4.  Promote teaching and specialty hospital programs;
1522	5.  Promote the stability and viability of statutorily
1523	defined rural hospitals and hospitals that serve as sole
1524	community hospitals;
1525	6.  Recognize the extent of hospital uncompensated care
1526	costs;
1527	7.  Maintain and enhance essential community hospital care;
1528	8.  Maintain incentives for local governmental entities to
1529	contribute to the cost of uncompensated care;
1530	9.  Promote measures to avoid preventable hospitalizations;
1531	10.  Account for hospital efficiency; and
1532	11.  Contribute to a community's overall health system.
1533	(2)  The Legislature intends for the capitated managed care
1534	pilot program to:
1535	(a)  Provide recipients in Medicaid fee-for-service or the
1536	MediPass program a comprehensive and coordinated capitated
1537	managed care system for all health care services specified in
1538	ss. 409.905 and 409.906.
1539	(b)  Stabilize Medicaid expenditures under the pilot
1540	program compared to Medicaid expenditures in the pilot area for
1541	the 3 years before implementation of the pilot program, while
1542	ensuring:
1543	1.  Consumer education and choice.
1544	2.  Access to medically necessary services.
1545	3.  Coordination of preventative, acute, and long-term
1546	care.
1547	4.  Reductions in unnecessary service utilization.
1548	(c)  Provide an opportunity to evaluate the feasibility of
1549	statewide implementation of capitated managed care networks as a
1550	replacement for the current Medicaid fee-for-service and
1551	MediPass systems.
1552	(3)  The agency shall have the following powers, duties,
1553	and responsibilities with respect to the pilot program:
1554	(a)  To implement a system to deliver all mandatory
1555	services specified in s. 409.905 and optional services specified
1556	in s. 409.906, as approved by the Centers for Medicare and
1557	Medicaid Services and the Legislature in the waiver pursuant to
1558	this section. Services to recipients under plan benefits shall
1559	include emergency services provided under s. 409.9128.
1560	(b)  To implement a pilot program, including Medicaid
1561	eligibility categories specified in ss. 409.903 and 409.904, as
1562	authorized in an approved federal waiver.
1563	(c)  To implement the managed care pilot program that
1564	maximizes all available state and federal funds, including those
1565	obtained through intergovernmental transfers, the low-income
1566	pool, supplemental Medicaid payments, and the disproportionate
1567	share program. Within the parameters allowed by federal statute
1568	and rule, the agency may seek options for making direct payments
1569	to hospitals and physicians employed by or under contract with
1570	the state's medical schools for the costs associated with
1571	graduate medical education under Medicaid reform.
1572	(d)  To implement actuarially sound, risk-adjusted
1573	capitation rates for Medicaid recipients in the pilot program
1574	which cover comprehensive care, enhanced services, and
1575	catastrophic care.
1576	(e)  To implement policies and guidelines for phasing in
1577	financial risk for approved provider service networks over a 3-
1578	year period. These policies and guidelines must include an
1579	option for a provider service network to be paid fee-for-service
1580	rates. For any provider service network established in a managed
1581	care pilot area, the option to be paid fee-for-service rates
1582	shall include a savings-settlement mechanism that is consistent
1583	with s. 409.912(44). Provider service networks opting to be paid
1584	fee-for-service rates shall have the option to be reimbursed for
1585	prescribed drugs and transportation services on a risk-adjusted
1586	captitated basis. This model shall be converted to a risk-
1587	adjusted capitated rate no later than the beginning of the
1588	fourth year of operation, and may be converted earlier at the
1589	option of the provider service network. Federally qualified
1590	health centers may be offered an opportunity to accept or
1591	decline a contract to participate in any provider network for
1592	prepaid primary care services. The agency shall encourage the
1593	development of innovative methods by provider service networks
1594	to perform administrative functions in a cost-effective manner,
1595	including coordination and consolidation of such functions
1596	between provider service networks and across demonstration
1597	sites.
1598	(f)  To implement stop-loss requirements and the transfer
1599	of excess cost to catastrophic coverage that accommodates the
1600	risks associated with the development of the pilot program.
1601	(g)  To recommend a process to be used by the Social
1602	Services Estimating Conference to determine and validate the
1603	rate of growth of the per-member costs of providing Medicaid
1604	services under the managed care pilot program.
1605	(h)  To implement program standards and credentialing
1606	requirements for capitated managed care networks to participate
1607	in the pilot program, including those related to fiscal
1608	solvency, quality of care, and adequacy of access to health care
1609	providers. The agency shall monitor quarterly and evaluate
1610	annually each plan based on the program standards and
1611	credentialing requirements for adequacy of access to health care
1612	providers to ensure consistent compliance. It is the intent of
1613	the Legislature that, to the extent possible, any pilot program
1614	authorized by the state under this section include any federally
1615	qualified health center, federally qualified rural health
1616	clinic, county health department, the Children's Medical
1617	Services Network within the Department of Health, or other
1618	federally, state, or locally funded entity that serves the
1619	geographic areas within the boundaries of the pilot program that
1620	requests to participate. This paragraph does not relieve an
1621	entity that qualifies as a capitated managed care network under
1622	this section from any other licensure or regulatory requirements
1623	contained in state or federal law which would otherwise apply to
1624	the entity. The standards and credentialing requirements shall
1625	be based upon, but are not limited to:
1626	1.  Compliance with the accreditation requirements as
1627	provided in s. 641.512.
1628	2.  Compliance with early and periodic screening,
1629	diagnosis, and treatment screening requirements under federal
1630	law.
1631	3.  The percentage of voluntary disenrollments.
1632	4.  Immunization rates.
1633	5.  Standards of the National Committee for Quality
1634	Assurance and other approved accrediting bodies.
1635	6.  Recommendations of other authoritative bodies.
1636	7.  Specific requirements of the Medicaid program, or
1637	standards designed to specifically meet the unique needs of
1638	Medicaid recipients.
1639	8.  Compliance with the health quality improvement system
1640	as established by the agency, which incorporates standards and
1641	guidelines developed by the Centers for Medicare and Medicaid
1642	Services as part of the quality assurance reform initiative.
1643	9.  The network's infrastructure capacity to manage
1644	financial transactions, recordkeeping, data collection, and
1645	other administrative functions.
1646	10.  The network's ability to submit any financial,
1647	programmatic, or patient-encounter data or other information
1648	required by the agency to determine the actual services provided
1649	and the cost of administering the plan.
1650	(i)  To implement a mechanism for providing information to
1651	Medicaid recipients for the purpose of selecting a capitated
1652	managed care plan. For each plan available to a recipient, the
1653	agency, at a minimum, shall ensure that the recipient is
1654	provided with:
1655	1.  A list and description of the benefits provided.
1656	2.  Information about cost sharing.
1657	3.  Plan performance data, if available.
1658	4.  An explanation of benefit limitations.
1659	5.  Contact information, including identification of
1660	providers participating in the network, geographic locations,
1661	and transportation limitations.
1662	6.  Specific information about covered prescription drugs
1663	for each plan.
1664	7.6.  Any other information the agency determines would
1665	facilitate a recipient's understanding of the plan or insurance
1666	that would best meet his or her needs.
1667	(j)  To implement a system to ensure that there is a record
1668	of recipient acknowledgment that choice counseling has been
1669	provided.
1670	(k)  To implement a choice counseling system to ensure that
1671	the choice counseling process and related material are designed
1672	to provide counseling through face-to-face interaction, by
1673	telephone, and in writing and through other forms of relevant
1674	media. Materials shall be written at the fourth-grade reading
1675	level and available in a language other than English when 5
1676	percent of the county speaks a language other than English.
1677	Choice counseling shall also use language lines and other
1678	services for impaired recipients, such as TTD/TTY.
1679	(l)  To implement a system that prohibits capitated managed
1680	care plans, their representatives, and providers employed by or
1681	contracted with the capitated managed care plans from recruiting
1682	persons eligible for or enrolled in Medicaid, from providing
1683	inducements to Medicaid recipients to select a particular
1684	capitated managed care plan, and from prejudicing Medicaid
1685	recipients against other capitated managed care plans. The
1686	system shall require the entity performing choice counseling to
1687	determine if the recipient has made a choice of a plan or has
1688	opted out because of duress, threats, payment to the recipient,
1689	or incentives promised to the recipient by a third party. If the
1690	choice counseling entity determines that the decision to choose
1691	a plan was unlawfully influenced or a plan violated any of the
1692	provisions of s. 409.912(21), the choice counseling entity shall
1693	immediately report the violation to the agency's program
1694	integrity section for investigation. Verification of choice
1695	counseling by the recipient shall include a stipulation that the
1696	recipient acknowledges the provisions of this subsection.
1697	(m)  To implement a choice counseling system that promotes
1698	health literacy and provides information aimed to reduce
1699	minority health disparities through outreach activities for
1700	Medicaid recipients.
1701	(n)  To contract with entities to perform choice
1702	counseling. The agency may establish standards and performance
1703	contracts, including standards requiring the contractor to hire
1704	choice counselors who are representative of the state's diverse
1705	population and to train choice counselors in working with
1706	culturally diverse populations.
1707	(o)  To implement eligibility assignment processes to
1708	facilitate client choice while ensuring pilot programs of
1709	adequate enrollment levels. These processes shall ensure that
1710	pilot sites have sufficient levels of enrollment to conduct a
1711	valid test of the managed care pilot program within a 2-year
1712	timeframe.
1713	(p)  To implement standards for plan compliance, including,
1714	but not limited to, standards for quality assurance and
1715	performance improvement, standards for peer or professional
1716	reviews, grievance policies, and policies for maintaining
1717	program integrity. The agency shall set reasonable standards for
1718	prompt payment of provider claims. The agency shall develop a
1719	data-reporting system, seek input from managed care plans in
1720	order to establish requirements for patient-encounter reporting,
1721	and ensure that the data reported is accurate and complete.
1722	1.  In performing the duties required under this section,
1723	the agency shall work with managed care plans to establish a
1724	uniform system to measure and monitor outcomes for a recipient
1725	of Medicaid services.
1726	2.  The system shall use financial, clinical, and other
1727	criteria based on pharmacy, medical services, and other data
1728	that is related to the provision of Medicaid services,
1729	including, but not limited to:
1730	a.  The Health Plan Employer Data and Information Set
1731	(HEDIS) or measures that are similar to HEDIS.
1732	b.  Member satisfaction.
1733	c.  Provider satisfaction.
1734	d.  Report cards on plan performance and best practices.
1735	e.  Compliance with the requirements for prompt payment of
1736	claims under ss. 627.613, 641.3155, and 641.513.
1737	f.  Utilization and quality data for the purpose of
1738	ensuring access to medically necessary services, including
1739	underutilization or inappropriate denial of services.
1740	3.  The agency shall require the managed care plans that
1741	have contracted with the agency to establish a quality assurance
1742	system that incorporates the provisions of s. 409.912(27) and
1743	any standards, rules, and guidelines developed by the agency.
1744	4.  The agency shall establish an encounter database in
1745	order to compile data on health services rendered by health care
1746	practitioners who provide services to patients enrolled in
1747	managed care plans in the demonstration sites. The encounter
1748	database shall:
1749	a.  Collect the following for each type of patient
1750	encounter with a health care practitioner or facility,
1751	including:
1752	(I)  The demographic characteristics of the patient.
1753	(II)  The principal, secondary, and tertiary diagnosis.
1754	(III)  The procedure performed.
1755	(IV)  The date and location where the procedure was
1756	performed.
1757	(V)  The payment for the procedure, if any.
1758	(VI)  If applicable, the health care practitioner's
1759	universal identification number.
1760	(VII)  If the health care practitioner rendering the
1761	service is a dependent practitioner, the modifiers appropriate
1762	to indicate that the service was delivered by the dependent
1763	practitioner.
1764	b.  Collect appropriate information relating to
1765	prescription drugs for each type of patient encounter.
1766	c.  Collect appropriate information related to health care
1767	costs and utilization from managed care plans participating in
1768	the demonstration sites.
1769	5.  To the extent practicable, when collecting the data the
1770	agency shall use a standardized claim form or electronic
1771	transfer system that is used by health care practitioners,
1772	facilities, and payors.
1773	6.  Health care practitioners and facilities in the
1774	demonstration sites shall electronically submit, and managed
1775	care plans participating in the demonstration sites shall
1776	electronically receive, information concerning claims payments
1777	and any other information reasonably related to the encounter
1778	database using a standard format as required by the agency.
1779	7.  The agency shall establish reasonable deadlines for
1780	phasing in the electronic transmittal of full encounter data.
1781	8.  The system must ensure that the data reported is
1782	accurate and complete.
1783	(q)  To implement a grievance resolution process for
1784	Medicaid recipients enrolled in a capitated managed care network
1785	under the pilot program modeled after the subscriber assistance
1786	panel, as created in s. 408.7056. This process shall include a
1787	mechanism for an expedited review of no greater than 24 hours
1788	after notification of a grievance if the life of a Medicaid
1789	recipient is in imminent and emergent jeopardy.
1790	(r)  To implement a grievance resolution process for health
1791	care providers employed by or contracted with a capitated
1792	managed care network under the pilot program in order to settle
1793	disputes among the provider and the managed care network or the
1794	provider and the agency.
1795	(s)  To implement criteria in an approved federal waiver to
1796	designate health care providers as eligible to participate in
1797	the pilot program. These criteria must include at a minimum
1798	those criteria specified in s. 409.907.
1799	(t)  To use health care provider agreements for
1800	participation in the pilot program.
1801	(u)  To require that all health care providers under
1802	contract with the pilot program be duly licensed in the state,
1803	if such licensure is available, and meet other criteria as may
1804	be established by the agency. These criteria shall include at a
1805	minimum those criteria specified in s. 409.907.
1806	(v)  To ensure that managed care organizations work
1807	collaboratively with other state or local governmental programs
1808	or institutions for the coordination of health care to eligible
1809	individuals receiving services from such programs or
1810	institutions.
1811	(w)  To implement procedures to minimize the risk of
1812	Medicaid fraud and abuse in all plans operating in the Medicaid
1813	managed care pilot program authorized in this section.
1814	1.  The agency shall ensure that applicable provisions of
1815	this chapter and chapters 414, 626, 641, and 932 which relate to
1816	Medicaid fraud and abuse are applied and enforced at the
1817	demonstration project sites.
1818	2.  Providers must have the certification, license, and
1819	credentials that are required by law and waiver requirements.
1820	3.  The agency shall ensure that the plan is in compliance
1821	with s. 409.912(21) and (22).
1822	4.  The agency shall require that each plan establish
1823	functions and activities governing program integrity in order to
1824	reduce the incidence of fraud and abuse. Plans must report
1825	instances of fraud and abuse pursuant to chapter 641.
1826	5.  The plan shall have written administrative and
1827	management arrangements or procedures, including a mandatory
1828	compliance plan, which are designed to guard against fraud and
1829	abuse. The plan shall designate a compliance officer who has
1830	sufficient experience in health care.
1831	6.a.  The agency shall require all managed care plan
1832	contractors in the pilot program to report all instances of
1833	suspected fraud and abuse. A failure to report instances of
1834	suspected fraud and abuse is a violation of law and subject to
1835	the penalties provided by law.
1836	b.  An instance of fraud and abuse in the managed care
1837	plan, including, but not limited to, defrauding the state health
1838	care benefit program by misrepresentation of fact in reports,
1839	claims, certifications, enrollment claims, demographic
1840	statistics, or patient-encounter data; misrepresentation of the
1841	qualifications of persons rendering health care and ancillary
1842	services; bribery and false statements relating to the delivery
1843	of health care; unfair and deceptive marketing practices; and
1844	false claims actions in the provision of managed care, is a
1845	violation of law and subject to the penalties provided by law.
1846	c.  The agency shall require that all contractors make all
1847	files and relevant billing and claims data accessible to state
1848	regulators and investigators and that all such data is linked
1849	into a unified system to ensure consistent reviews and
1850	investigations.
1851	(x)  To develop and provide actuarial and benefit design
1852	analyses that indicate the effect on capitation rates and
1853	benefits offered in the pilot program over a prospective 5-year
1854	period based on the following assumptions:
1855	1.  Growth in capitation rates which is limited to the
1856	estimated growth rate in general revenue.
1857	2.  Growth in capitation rates which is limited to the
1858	average growth rate over the last 3 years in per-recipient
1859	Medicaid expenditures.
1860	3.  Growth in capitation rates which is limited to the
1861	growth rate of aggregate Medicaid expenditures between the 2003-
1862	2004 fiscal year and the 2004-2005 fiscal year.
1863	(y)  To develop a mechanism to require capitated managed
1864	care plans to reimburse qualified emergency service providers,
1865	including, but not limited to, ambulance services, in accordance
1866	with ss. 409.908 and 409.9128. The pilot program must include a
1867	provision for continuing fee-for-service payments for emergency
1868	services, including, but not limited to, individuals who access
1869	ambulance services or emergency departments and who are
1870	subsequently determined to be eligible for Medicaid services.
1871	(z)  To ensure that school districts participating in the
1872	certified school match program pursuant to ss. 409.908(21) and
1873	1011.70 shall be reimbursed by Medicaid, subject to the
1874	limitations of s. 1011.70(1), for a Medicaid-eligible child
1875	participating in the services as authorized in s. 1011.70, as
1876	provided for in s. 409.9071, regardless of whether the child is
1877	enrolled in a capitated managed care network. Capitated managed
1878	care networks must make a good faith effort to execute
1879	agreements with school districts regarding the coordinated
1880	provision of services authorized under s. 1011.70. County health
1881	departments and federally qualified health centers delivering
1882	school-based services pursuant to ss. 381.0056 and 381.0057 must
1883	be reimbursed by Medicaid for the federal share for a Medicaid-
1884	eligible child who receives Medicaid-covered services in a
1885	school setting, regardless of whether the child is enrolled in a
1886	capitated managed care network. Capitated managed care networks
1887	must make a good faith effort to execute agreements with county
1888	health departments and federally qualified health centers
1889	regarding the coordinated provision of services to a Medicaid-
1890	eligible child. To ensure continuity of care for Medicaid
1891	patients, the agency, the Department of Health, and the
1892	Department of Education shall develop procedures for ensuring
1893	that a student's capitated managed care network provider
1894	receives information relating to services provided in accordance
1895	with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
1896	(aa)  To implement a mechanism whereby Medicaid recipients
1897	who are already enrolled in a managed care plan or the MediPass
1898	program in the pilot areas shall be offered the opportunity to
1899	change to capitated managed care plans on a staggered basis, as
1900	defined by the agency. All Medicaid recipients shall have 30
1901	days in which to make a choice of capitated managed care plans.
1902	Those Medicaid recipients who do not make a choice shall be
1903	assigned to a capitated managed care plan in accordance with
1904	paragraph (4)(a) and shall be exempt from s. 409.9122. To
1905	facilitate continuity of care for a Medicaid recipient who is
1906	also a recipient of Supplemental Security Income (SSI), prior to
1907	assigning the SSI recipient to a capitated managed care plan,
1908	the agency shall determine whether the SSI recipient has an
1909	ongoing relationship with a provider or capitated managed care
1910	plan, and, if so, the agency shall assign the SSI recipient to
1911	that provider or capitated managed care plan where feasible.
1912	Those SSI recipients who do not have such a provider
1913	relationship shall be assigned to a capitated managed care plan
1914	provider in accordance with paragraph (4)(a) and shall be exempt
1915	from s. 409.9122.
1916	(bb)  To develop and recommend a service delivery
1917	alternative for children having chronic medical conditions which
1918	establishes a medical home project to provide primary care
1919	services to this population. The project shall provide
1920	community-based primary care services that are integrated with
1921	other subspecialties to meet the medical, developmental, and
1922	emotional needs for children and their families. This project
1923	shall include an evaluation component to determine impacts on
1924	hospitalizations, length of stays, emergency room visits, costs,
1925	and access to care, including specialty care and patient and
1926	family satisfaction.
1927	(cc)  To develop and recommend service delivery mechanisms
1928	within capitated managed care plans to provide Medicaid services
1929	as specified in ss. 409.905 and 409.906 to persons with
1930	developmental disabilities sufficient to meet the medical,
1931	developmental, and emotional needs of these persons.
1932	(dd)  To implement service delivery mechanisms within
1933	capitated managed care plans to provide Medicaid services as
1934	specified in ss. 409.905 and 409.906 to Medicaid-eligible
1935	children whose cases are open for child welfare services in the
1936	HomeSafeNet system. These services must be coordinated with
1937	community-based care providers as specified in s. 409.1671,
1938	where available, and be sufficient to meet the medical,
1939	developmental, behavioral, and emotional needs of these
1940	children. These service delivery mechanisms must be implemented
1941	no later than July 1, 2008, in AHCA area 10 in order for the
1942	children in AHCA area 10 to remain exempt from the statewide
1943	plan under s. 409.912(4)(b)8.
1944	(4)(a)  A Medicaid recipient in the pilot area who is not
1945	currently enrolled in a capitated managed care plan upon
1946	implementation is not eligible for services as specified in ss.
1947	409.905 and 409.906, for the amount of time that the recipient
1948	does not enroll in a capitated managed care network. If a
1949	Medicaid recipient has not enrolled in a capitated managed care
1950	plan within 30 days after eligibility, the agency shall assign
1951	the Medicaid recipient to a provider service network. The agency
1952	shall assign such recipients to provider service networks for
1953	the first 5 years of implementation of each demonstration site
1954	or until the number of recipients enrolled in provider service
1955	networks in that demonstration site reaches 10 percent of the
1956	total number of participating Medicaid recipients in that
1957	demonstration site, whichever is first. After that time, if a
1958	Medicaid recipient has not enrolled in a capitated managed care
1959	plan within 30 days after eligibility, the agency shall assign
1960	the Medicaid recipient to a capitated managed care plan based on
1961	the assessed needs of the recipient as determined by the agency,
1962	and the recipient shall be exempt from s. 409.9122. When making
1963	such assignments, the agency shall take into account the
1964	following criteria:
1965	1.  A capitated managed care network has sufficient network
1966	capacity to meet the needs of members.
1967	2.  The capitated managed care network has previously
1968	enrolled the recipient as a member, or one of the capitated
1969	managed care network's primary care providers has previously
1970	provided health care to the recipient.
1971	3.  The agency has knowledge that the member has previously
1972	expressed a preference for a particular capitated managed care
1973	network as indicated by Medicaid fee-for-service claims data,
1974	but has failed to make a choice.
1975	4.  The capitated managed care network's primary care
1976	providers are geographically accessible to the recipient's
1977	residence.
1978	(b)  When more than one capitated managed care network
1979	provider meets the criteria specified in paragraph (3)(h), the
1980	agency shall make recipient assignments consecutively by family
1981	unit.
1982	(c)  If a recipient is currently enrolled with a Medicaid
1983	managed care organization that also operates an approved reform
1984	plan within a demonstration area and the recipient fails to
1985	choose a plan during the reform enrollment process or during
1986	redetermination of eligibility, the recipient shall be
1987	automatically assigned by the agency to a provider service
1988	network. The agency shall assign such recipients to provider
1989	service networks for the first 5 years of implementation of each
1990	demonstration site or until the number of recipients enrolled in
1991	provider service networks in that demonstration site reaches 10
1992	percent of the total number of participating Medicaid recipients
1993	in that demonstration site, whichever is first. After that time
1994	into the most appropriate reform plan operated by the
1995	recipient's current Medicaid managed care plan. If the
1996	recipient's current managed care plan does not operate a reform
1997	plan in the demonstration area which adequately meets the needs
1998	of the Medicaid recipient, the agency shall use the automatic
1999	assignment process as prescribed in the special terms and
2000	conditions numbered 11-W-00206/4. All enrollment and choice
2001	counseling materials provided by the agency must contain an
2002	explanation of the provisions of this paragraph for current
2003	managed care recipients.
2004	(d)  The agency may not engage in practices that are
2005	designed to favor one capitated managed care plan over another
2006	or that are designed to influence Medicaid recipients to enroll
2007	in a particular capitated managed care network in order to
2008	strengthen its particular fiscal viability.
2009	(e)  After a recipient has made a selection or has been
2010	enrolled in a capitated managed care network, the recipient
2011	shall have 90 days in which to voluntarily disenroll and select
2012	another capitated managed care network. After 90 days, no
2013	further changes may be made except for cause. Cause shall
2014	include, but not be limited to, poor quality of care, lack of
2015	access to necessary specialty services, an unreasonable delay or
2016	denial of service, inordinate or inappropriate changes of
2017	primary care providers, service access impairments due to
2018	significant changes in the geographic location of services, or
2019	fraudulent enrollment. The agency may require a recipient to use
2020	the capitated managed care network's grievance process as
2021	specified in paragraph (3)(q) prior to the agency's
2022	determination of cause, except in cases in which immediate risk
2023	of permanent damage to the recipient's health is alleged. The
2024	grievance process, when used, must be completed in time to
2025	permit the recipient to disenroll no later than the first day of
2026	the second month after the month the disenrollment request was
2027	made. If the capitated managed care network, as a result of the
2028	grievance process, approves an enrollee's request to disenroll,
2029	the agency is not required to make a determination in the case.
2030	The agency must make a determination and take final action on a
2031	recipient's request so that disenrollment occurs no later than
2032	the first day of the second month after the month the request
2033	was made. If the agency fails to act within the specified
2034	timeframe, the recipient's request to disenroll is deemed to be
2035	approved as of the date agency action was required. Recipients
2036	who disagree with the agency's finding that cause does not exist
2037	for disenrollment shall be advised of their right to pursue a
2038	Medicaid fair hearing to dispute the agency's finding.
2039	(f)  The agency shall apply for federal waivers from the
2040	Centers for Medicare and Medicaid Services to lock eligible
2041	Medicaid recipients into a capitated managed care network for 12
2042	months after an open enrollment period. After 12 months of
2043	enrollment, a recipient may select another capitated managed
2044	care network. However, nothing shall prevent a Medicaid
2045	recipient from changing primary care providers within the
2046	capitated managed care network during the 12-month period.
2047	(g)  The agency shall apply for federal waivers from the
2048	Centers for Medicare and Medicaid Services to allow recipients
2049	to purchase health care coverage through an employer-sponsored
2050	health insurance plan instead of through a Medicaid-certified
2051	plan. This provision shall be known as the opt-out option.
2052	1.  A recipient who chooses the Medicaid opt-out option
2053	shall have an opportunity for a specified period of time, as
2054	authorized under a waiver granted by the Centers for Medicare
2055	and Medicaid Services, to select and enroll in a Medicaid-
2056	certified plan. If the recipient remains in the employer-
2057	sponsored plan after the specified period, the recipient shall
2058	remain in the opt-out program for at least 1 year or until the
2059	recipient no longer has access to employer-sponsored coverage,
2060	until the employer's open enrollment period for a person who
2061	opts out in order to participate in employer-sponsored coverage,
2062	or until the person is no longer eligible for Medicaid,
2063	whichever time period is shorter.
2064	2.  Notwithstanding any other provision of this section,
2065	coverage, cost sharing, and any other component of employer-
2066	sponsored health insurance shall be governed by applicable state
2067	and federal laws.
2068	(5)  This section does not authorize the agency to
2069	implement any provision of s. 1115 of the Social Security Act
2070	experimental, pilot, or demonstration project waiver to reform
2071	the state Medicaid program in any part of the state other than
2072	the two geographic areas specified in this section unless
2073	approved by the Legislature.
2074	(6)  The agency shall develop and submit for approval
2075	applications for waivers of applicable federal laws and
2076	regulations as necessary to implement the managed care pilot
2077	project as defined in this section. The agency shall post all
2078	waiver applications under this section on its Internet website
2079	30 days before submitting the applications to the United States
2080	Centers for Medicare and Medicaid Services. All waiver
2081	applications shall be provided for review and comment to the
2082	appropriate committees of the Senate and House of
2083	Representatives for at least 10 working days prior to
2084	submission. All waivers submitted to and approved by the United
2085	States Centers for Medicare and Medicaid Services under this
2086	section must be approved by the Legislature. Federally approved
2087	waivers must be submitted to the President of the Senate and the
2088	Speaker of the House of Representatives for referral to the
2089	appropriate legislative committees. The appropriate committees
2090	shall recommend whether to approve the implementation of any
2091	waivers to the Legislature as a whole. The agency shall submit a
2092	plan containing a recommended timeline for implementation of any
2093	waivers and budgetary projections of the effect of the pilot
2094	program under this section on the total Medicaid budget for the
2095	2006-2007 through 2009-2010 state fiscal years. This
2096	implementation plan shall be submitted to the President of the
2097	Senate and the Speaker of the House of Representatives at the
2098	same time any waivers are submitted for consideration by the
2099	Legislature. The agency may implement the waiver and special
2100	terms and conditions numbered 11-W-00206/4, as approved by the
2101	federal Centers for Medicare and Medicaid Services. If the
2102	agency seeks approval by the Federal Government of any
2103	modifications to these special terms and conditions, the agency
2104	must provide written notification of its intent to modify these
2105	terms and conditions to the President of the Senate and the
2106	Speaker of the House of Representatives at least 15 days before
2107	submitting the modifications to the Federal Government for
2108	consideration. The notification must identify all modifications
2109	being pursued and the reason the modifications are needed. Upon
2110	receiving federal approval of any modifications to the special
2111	terms and conditions, the agency shall provide a report to the
2112	Legislature describing the federally approved modifications to
2113	the special terms and conditions within 7 days after approval by
2114	the Federal Government.
2115	(7)(a)  The Secretary of Health Care Administration shall
2116	convene a technical advisory panel to advise the agency in the
2117	areas of risk-adjusted-rate setting, benefit design, and choice
2118	counseling. The panel shall include representatives from the
2119	Florida Association of Health Plans, representatives from
2120	provider-sponsored networks, a Medicaid consumer representative,
2121	and a representative from the Office of Insurance Regulation.
2122	(b)  The technical advisory panel shall advise the agency
2123	concerning:
2124	1.  The risk-adjusted rate methodology to be used by the
2125	agency, including recommendations on mechanisms to recognize the
2126	risk of all Medicaid enrollees and for the transition to a risk-
2127	adjustment system, including recommendations for phasing in risk
2128	adjustment and the use of risk corridors.
2129	2.  Implementation of an encounter data system to be used
2130	for risk-adjusted rates.
2131	3.  Administrative and implementation issues regarding the
2132	use of risk-adjusted rates, including, but not limited to, cost,
2133	simplicity, client privacy, data accuracy, and data exchange.
2134	4.  Issues of benefit design, including the actuarial
2135	equivalence and sufficiency standards to be used.
2136	5.  The implementation plan for the proposed choice-
2137	counseling system, including the information and materials to be
2138	provided to recipients, the methodologies by which recipients
2139	will be counseled regarding choice, criteria to be used to
2140	assess plan quality, the methodology to be used to assign
2141	recipients into plans if they fail to choose a managed care
2142	plan, and the standards to be used for responsiveness to
2143	recipient inquiries.
2144	(c)  The technical advisory panel shall continue in
2145	existence and advise the agency on matters outlined in this
2146	subsection.
2147	(8)  The agency must ensure, in the first two state fiscal
2148	years in which a risk-adjusted methodology is a component of
2149	rate setting, that no managed care plan providing comprehensive
2150	benefits to TANF and SSI recipients has an aggregate risk score
2151	that varies by more than 10 percent from the aggregate weighted
2152	mean of all managed care plans providing comprehensive benefits
2153	to TANF and SSI recipients in a reform area. The agency's
2154	payment to a managed care plan shall be based on such revised
2155	aggregate risk score.
2156	(9)  After any calculations of aggregate risk scores or
2157	revised aggregate risk scores in subsection (8), the capitation
2158	rates for plans participating under this section shall be phased
2159	in as follows:
2160	(a)  In the first year, the capitation rates shall be
2161	weighted so that 75 percent of each capitation rate is based on
2162	the current methodology and 25 percent is based on a new risk-
2163	adjusted capitation rate methodology.
2164	(b)  In the second year, the capitation rates shall be
2165	weighted so that 50 percent of each capitation rate is based on
2166	the current methodology and 50 percent is based on a new risk-
2167	adjusted rate methodology.
2168	(c)  In the following fiscal year, the risk-adjusted
2169	capitation methodology may be fully implemented.
2170	(10)  Subsections (8) and (9) do not apply to managed care
2171	plans offering benefits exclusively to high-risk, specialty
2172	populations. The agency may set risk-adjusted rates immediately
2173	for such plans.
2174	(11)  Before the implementation of risk-adjusted rates, the
2175	rates shall be certified by an actuary and approved by the
2176	federal Centers for Medicare and Medicaid Services.
2177	(12)  For purposes of this section, the term "capitated
2178	managed care plan" includes health insurers authorized under
2179	chapter 624, exclusive provider organizations authorized under
2180	chapter 627, health maintenance organizations authorized under
2181	chapter 641, the Children's Medical Services Network under
2182	chapter 391, and provider service networks that elect to be paid
2183	fee-for-service for up to 3 years as authorized under this
2184	section.
2185	(13)  Upon review and approval of the applications for
2186	waivers of applicable federal laws and regulations to implement
2187	the managed care pilot program by the Legislature, the agency
2188	may initiate adoption of rules pursuant to ss. 120.536(1) and
2189	120.54 to implement and administer the managed care pilot
2190	program as provided in this section.
2191	(14)  It is the intent of the Legislature that if any
2192	conflict exists between the provisions contained in this section
2193	and other provisions of this chapter which relate to the
2194	implementation of the Medicaid managed care pilot program, the
2195	provisions contained in this section shall control. The agency
2196	shall provide a written report to the Legislature by April 1,
2197	2006, identifying any provisions of this chapter which conflict
2198	with the implementation of the Medicaid managed care pilot
2199	program created in this section. After April 1, 2006, the agency
2200	shall provide a written report to the Legislature immediately
2201	upon identifying any provisions of this chapter which conflict
2202	with the implementation of the Medicaid managed care pilot
2203	program created in this section.
2204	Section 14.  Subsection (2) of section 409.9124, Florida
2205	Statutes, is amended to read:
2206	409.9124  Managed care reimbursement.--The agency shall
2207	develop and adopt by rule a methodology for reimbursing managed
2208	care plans.
2209	(2)  Each year prior to establishing new managed care
2210	rates, the agency shall review all prior year adjustments for
2211	changes in trend, and shall reduce or eliminate those
2212	adjustments which are not reasonable and which reflect policies
2213	or programs which are not in effect. In addition, the agency
2214	shall apply only those policy reductions applicable to the
2215	fiscal year for which the rates are being set, which can be
2216	accurately estimated and verified by an independent actuary, and
2217	which have been implemented prior to or will be implemented
2218	during the fiscal year. The agency shall pay rates at per-
2219	member, per-month averages that do not exceed the amounts
2220	allowed for in the General Appropriations Act applicable to the
2221	fiscal year for which the rates will be in effect.
2222	Section 15.  Subsection (36) of section 409.913, Florida
2223	Statutes, is amended to read:
2224	409.913  Oversight of the integrity of the Medicaid
2225	program.--The agency shall operate a program to oversee the
2226	activities of Florida Medicaid recipients, and providers and
2227	their representatives, to ensure that fraudulent and abusive
2228	behavior and neglect of recipients occur to the minimum extent
2229	possible, and to recover overpayments and impose sanctions as
2230	appropriate. Beginning January 1, 2003, and each year
2231	thereafter, the agency and the Medicaid Fraud Control Unit of
2232	the Department of Legal Affairs shall submit a joint report to
2233	the Legislature documenting the effectiveness of the state's
2234	efforts to control Medicaid fraud and abuse and to recover
2235	Medicaid overpayments during the previous fiscal year. The
2236	report must describe the number of cases opened and investigated
2237	each year; the sources of the cases opened; the disposition of
2238	the cases closed each year; the amount of overpayments alleged
2239	in preliminary and final audit letters; the number and amount of
2240	fines or penalties imposed; any reductions in overpayment
2241	amounts negotiated in settlement agreements or by other means;
2242	the amount of final agency determinations of overpayments; the
2243	amount deducted from federal claiming as a result of
2244	overpayments; the amount of overpayments recovered each year;
2245	the amount of cost of investigation recovered each year; the
2246	average length of time to collect from the time the case was
2247	opened until the overpayment is paid in full; the amount
2248	determined as uncollectible and the portion of the uncollectible
2249	amount subsequently reclaimed from the Federal Government; the
2250	number of providers, by type, that are terminated from
2251	participation in the Medicaid program as a result of fraud and
2252	abuse; and all costs associated with discovering and prosecuting
2253	cases of Medicaid overpayments and making recoveries in such
2254	cases. The report must also document actions taken to prevent
2255	overpayments and the number of providers prevented from
2256	enrolling in or reenrolling in the Medicaid program as a result
2257	of documented Medicaid fraud and abuse and must recommend
2258	changes necessary to prevent or recover overpayments.
2259	(36)  The agency shall provide to each Medicaid recipient
2260	or his or her representative an explanation of benefits in the
2261	form of a letter that is mailed to the most recent address of
2262	the recipient on the record with the Department of Children and
2263	Family Services. The explanation of benefits must include the
2264	patient's name, the name of the health care provider and the
2265	address of the location where the service was provided, a
2266	description of all services billed to Medicaid in terminology
2267	that should be understood by a reasonable person, and
2268	information on how to report inappropriate or incorrect billing
2269	to the agency or other law enforcement entities for review or
2270	investigation. The explanation of benefits may not be mailed for
2271	Medicaid independent laboratory services as described in s.
2272	409.905(7) or for Medicaid certified match services as described
2273	in ss. 409.9071 and 1011.70.
2274	Section 16.  Paragraph (a) of subsection (8) of section
2275	39.001, Florida Statutes, is amended to read:
2276	39.001  Purposes and intent; personnel standards and
2277	screening.--
2278	(8)  PLAN FOR COMPREHENSIVE APPROACH.--
2279	(a)  The office shall develop a state plan for the
2280	promotion of adoption, support of adoptive families, and
2281	prevention of abuse, abandonment, and neglect of children and
2282	shall submit the state plan to the Speaker of the House of
2283	Representatives, the President of the Senate, and the Governor
2284	no later than December 31, 2008. The Department of Children and
2285	Family Services, the Department of Corrections, the Department
2286	of Education, the Department of Health, the Department of
2287	Juvenile Justice, the Department of Law Enforcement, the Agency
2288	for Persons with Disabilities, and the Agency for Workforce
2289	Innovation shall participate and fully cooperate in the
2290	development of the state plan at both the state and local
2291	levels. Furthermore, appropriate local agencies and
2292	organizations shall be provided an opportunity to participate in
2293	the development of the state plan at the local level.
2294	Appropriate local groups and organizations shall include, but
2295	not be limited to, community mental health centers; guardian ad
2296	litem programs for children under the circuit court; the school
2297	boards of the local school districts; the Florida local advocacy
2298	councils; community-based care lead agencies; private or public
2299	organizations or programs with recognized expertise in working
2300	with child abuse prevention programs for children and families;
2301	private or public organizations or programs with recognized
2302	expertise in working with children who are sexually abused,
2303	physically abused, emotionally abused, abandoned, or neglected
2304	and with expertise in working with the families of such
2305	children; private or public programs or organizations with
2306	expertise in maternal and infant health care; multidisciplinary
2307	child protection teams; child day care centers; law enforcement
2308	agencies; and the circuit courts, when guardian ad litem
2309	programs are not available in the local area. The state plan to
2310	be provided to the Legislature and the Governor shall include,
2311	as a minimum, the information required of the various groups in
2312	paragraph (b).
2313	Section 17.  Subsection (2) of section 39.0011, Florida
2314	Statutes, is amended to read:
2315	39.0011  Direct-support organization.--
2316	(2)  The number of members on the board of directors of the
2317	direct-support organization shall be determined by the Chief
2318	Child Advocate. Membership on the board of directors of the
2319	direct-support organization shall include, but not be limited
2320	to, a guardian ad litem; a member of a local advocacy council; a
2321	representative from a community-based care lead agency; a
2322	representative from a private or public organization or program
2323	with recognized expertise in working with child abuse prevention
2324	programs for children and families; a representative of a
2325	private or public organization or program with recognized
2326	expertise in working with children who are sexually abused,
2327	physically abused, emotionally abused, abandoned, or neglected
2328	and with expertise in working with the families of such
2329	children; an individual working at a state adoption agency; and
2330	the parent of a child adopted from within the child welfare
2331	system.
2332	Section 18.  Paragraph (k) of subsection (2) of section
2333	39.202, Florida Statutes, is amended to read:
2334	39.202  Confidentiality of reports and records in cases of
2335	child abuse or neglect.--
2336	(2)  Except as provided in subsection (4), access to such
2337	records, excluding the name of the reporter which shall be
2338	released only as provided in subsection (5), shall be granted
2339	only to the following persons, officials, and agencies:
2340	(k)  Any appropriate official of a Florida advocacy council
2341	investigating a report of known or suspected child abuse,
2342	abandonment, or neglect; The Auditor General or the Office of
2343	Program Policy Analysis and Government Accountability for the
2344	purpose of conducting audits or examinations pursuant to law; or
2345	the guardian ad litem for the child.
2346	Section 19.  Subsections (5), (6), and (7) of section
2347	39.302, Florida Statutes, are renumbered as subsections (4),
2348	(5), and (6), respectively, and present subsection (4) is
2349	amended to read:
2350	39.302  Protective investigations of institutional child
2351	abuse, abandonment, or neglect.--
2352	(4)  The department shall notify the Florida local advocacy
2353	council in the appropriate district of the department as to
2354	every report of institutional child abuse, abandonment, or
2355	neglect in the district in which a client of the department is
2356	alleged or shown to have been abused, abandoned, or neglected,
2357	which notification shall be made within 48 hours after the
2358	department commences its investigation.
2359	Section 20.  Paragraph (v) of subsection (1) of section
2360	215.22, Florida Statutes, is redesignated as paragraph (u), and
2361	present paragraph (u) of that subsection is amended to read:
2362	215.22  Certain income and certain trust funds exempt.--
2363	(1)  The following income of a revenue nature or the
2364	following trust funds shall be exempt from the appropriation
2365	required by s. 215.20(1):
2366	(u)  The Florida Center for Nursing Trust Fund.
2367	Section 21.  Paragraph (c) of subsection (5) and subsection
2368	(12) of section 394.459, Florida Statutes, are amended to read:
2369	394.459  Rights of patients.--
2370	(5)  COMMUNICATION, ABUSE REPORTING, AND VISITS.--
2371	(c)  Each facility must permit immediate access to any
2372	patient, subject to the patient's right to deny or withdraw
2373	consent at any time, by the patient's family members, guardian,
2374	guardian advocate, representative, Florida statewide or local
2375	advocacy council, or attorney, unless such access would be
2376	detrimental to the patient. If a patient's right to communicate
2377	or to receive visitors is restricted by the facility, written
2378	notice of such restriction and the reasons for the restriction
2379	shall be served on the patient, the patient's attorney, and the
2380	patient's guardian, guardian advocate, or representative; and
2381	such restriction shall be recorded on the patient's clinical
2382	record with the reasons therefor. The restriction of a patient's
2383	right to communicate or to receive visitors shall be reviewed at
2384	least every 7 days. The right to communicate or receive visitors
2385	shall not be restricted as a means of punishment. Nothing in
2386	this paragraph shall be construed to limit the provisions of
2387	paragraph (d).
2388	(12)  POSTING OF NOTICE OF RIGHTS OF PATIENTS.--Each
2389	facility shall post a notice listing and describing, in the
2390	language and terminology that the persons to whom the notice is
2391	addressed can understand, the rights provided in this section.
2392	This notice shall include a statement that provisions of the
2393	federal Americans with Disabilities Act apply and the name and
2394	telephone number of a person to contact for further information.
2395	This notice shall be posted in a place readily accessible to
2396	patients and in a format easily seen by patients. This notice
2397	shall include the telephone number numbers of the Florida local
2398	advocacy council and Advocacy Center for Persons with
2399	Disabilities, Inc.
2400	Section 22.  Paragraph (d) of subsection (2) of section
2401	394.4597, Florida Statutes, is amended to read:
2402	394.4597  Persons to be notified; patient's
2403	representative.--
2404	(2)  INVOLUNTARY PATIENTS.--
2405	(d)  When the receiving or treatment facility selects a
2406	representative, first preference shall be given to a health care
2407	surrogate, if one has been previously selected by the patient.
2408	If the patient has not previously selected a health care
2409	surrogate, the selection, except for good cause documented in
2410	the patient's clinical record, shall be made from the following
2411	list in the order of listing:
2412	1.  The patient's spouse.
2413	2.  An adult child of the patient.
2414	3.  A parent of the patient.
2415	4.  The adult next of kin of the patient.
2416	5.  An adult friend of the patient.
2417	6.  The appropriate Florida local advocacy council as
2418	provided in s. 402.166.
2419	Section 23.  Subsection (1) of section 394.4598, Florida
2420	Statutes, is amended to read:
2421	394.4598  Guardian advocate.--
2422	(1)  The administrator may petition the court for the
2423	appointment of a guardian advocate based upon the opinion of a
2424	psychiatrist that the patient is incompetent to consent to
2425	treatment. If the court finds that a patient is incompetent to
2426	consent to treatment and has not been adjudicated incapacitated
2427	and a guardian with the authority to consent to mental health
2428	treatment appointed, it shall appoint a guardian advocate. The
2429	patient has the right to have an attorney represent him or her
2430	at the hearing. If the person is indigent, the court shall
2431	appoint the office of the public defender to represent him or
2432	her at the hearing. The patient has the right to testify, cross-
2433	examine witnesses, and present witnesses. The proceeding shall
2434	be recorded either electronically or stenographically, and
2435	testimony shall be provided under oath. One of the professionals
2436	authorized to give an opinion in support of a petition for
2437	involuntary placement, as described in s. 394.4655 or s.
2438	394.467, must testify. A guardian advocate must meet the
2439	qualifications of a guardian contained in part IV of chapter
2440	744, except that a professional referred to in this part, an
2441	employee of the facility providing direct services to the
2442	patient under this part, a departmental employee, or a facility
2443	administrator, or member of the Florida local advocacy council
2444	shall not be appointed. A person who is appointed as a guardian
2445	advocate must agree to the appointment.
2446	Section 24.  Paragraph (b) of subsection (2) of section
2447	394.4599, Florida Statutes, is amended to read:
2448	394.4599  Notice.--
2449	(2)  INVOLUNTARY PATIENTS.--
2450	(b)  A receiving facility shall give prompt notice of the
2451	whereabouts of a patient who is being involuntarily held for
2452	examination, by telephone or in person within 24 hours after the
2453	patient's arrival at the facility, unless the patient requests
2454	that no notification be made. Contact attempts shall be
2455	documented in the patient's clinical record and shall begin as
2456	soon as reasonably possible after the patient's arrival. Notice
2457	that a patient is being admitted as an involuntary patient shall
2458	be given to the Florida local advocacy council no later than the
2459	next working day after the patient is admitted.
2460	Section 25.  Subsection (5) of section 394.4615, Florida
2461	Statutes, is amended to read:
2462	394.4615  Clinical records; confidentiality.--
2463	(5)  Information from clinical records may be used by the
2464	Agency for Health Care Administration and, the department, and
2465	the Florida advocacy councils for the purpose of monitoring
2466	facility activity and complaints concerning facilities.
2467	Section 26.  Paragraphs (h) and (i) of subsection (2) of
2468	section 400.0065, Florida Statutes, are redesignated as
2469	paragraphs (g) and (h), respectively, and present paragraph (g)
2470	of that subsection is amended to read:
2471	400.0065  State Long-Term Care Ombudsman; duties and
2472	responsibilities.--
2473	(2)  The State Long-Term Care Ombudsman shall have the duty
2474	and authority to:
2475	(g)  Enter into a cooperative agreement with the Statewide
2476	Advocacy Council for the purpose of coordinating and avoiding
2477	duplication of advocacy services provided to residents.
2478	Section 27.  Paragraph (a) of subsection (2) of section
2479	400.118, Florida Statutes, is amended to read:
2480	400.118  Quality assurance; early warning system;
2481	monitoring; rapid response teams.--
2482	(2)(a)  The agency shall establish within each district
2483	office one or more quality-of-care monitors, based on the number
2484	of nursing facilities in the district, to monitor all nursing
2485	facilities in the district on a regular, unannounced, aperiodic
2486	basis, including nights, evenings, weekends, and holidays.
2487	Quality-of-care monitors shall visit each nursing facility at
2488	least quarterly. Priority for additional monitoring visits shall
2489	be given to nursing facilities with a history of resident care
2490	deficiencies. Quality-of-care monitors shall be registered
2491	nurses who are trained and experienced in nursing facility
2492	regulation, standards of practice in long-term care, and
2493	evaluation of patient care. Individuals in these positions shall
2494	not be deployed by the agency as a part of the district survey
2495	team in the conduct of routine, scheduled surveys, but shall
2496	function solely and independently as quality-of-care monitors.
2497	Quality-of-care monitors shall assess the overall quality of
2498	life in the nursing facility and shall assess specific
2499	conditions in the facility directly related to resident care,
2500	including the operations of internal quality improvement and
2501	risk management programs and adverse incident reports. The
2502	quality-of-care monitor shall include in an assessment visit
2503	observation of the care and services rendered to residents and
2504	formal and informal interviews with residents, family members,
2505	facility staff, resident guests, volunteers, other regulatory
2506	staff, and representatives of a long-term care ombudsman council
2507	or Florida advocacy council.
2508	Section 28.  Subsections (13) and (20) of section 400.141,
2509	Florida Statutes, are amended to read:
2510	400.141  Administration and management of nursing home
2511	facilities.--Every licensed facility shall comply with all
2512	applicable standards and rules of the agency and shall:
2513	(13)  Publicly display a poster provided by the agency
2514	containing the names, addresses, and telephone numbers for the
2515	state's abuse hotline, the State Long-Term Care Ombudsman, the
2516	Agency for Health Care Administration consumer hotline, the
2517	Advocacy Center for Persons with Disabilities, the Florida
2518	Statewide Advocacy Council, and the Medicaid Fraud Control Unit,
2519	with a clear description of the assistance to be expected from
2520	each.
2521	(20)  Maintain general and professional liability insurance
2522	coverage that is in force at all times. In lieu of general and
2523	professional liability insurance coverage, a state-designated
2524	teaching nursing home and its affiliated assisted living
2525	facilities created under s. 430.80 may demonstrate proof of
2526	financial responsibility as provided in s. 430.80(3)(h).
2527
2528	Facilities that have been awarded a Gold Seal under the program
2529	established in s. 400.235 may develop a plan to provide
2530	certified nursing assistant training as prescribed by federal
2531	regulations and state rules and may apply to the agency for
2532	approval of their program.
2533	Section 29.  Paragraph (a) of subsection (1) of section
2534	415.1034, Florida Statutes, is amended to read:
2535	415.1034  Mandatory reporting of abuse, neglect, or
2536	exploitation of vulnerable adults; mandatory reports of death.--
2537	(1)  MANDATORY REPORTING.--
2538	(a)  Any person, including, but not limited to, any:
2539	1.  Physician, osteopathic physician, medical examiner,
2540	chiropractic physician, nurse, paramedic, emergency medical
2541	technician, or hospital personnel engaged in the admission,
2542	examination, care, or treatment of vulnerable adults;
2543	2.  Health professional or mental health professional other
2544	than one listed in subparagraph 1.;
2545	3.  Practitioner who relies solely on spiritual means for
2546	healing;
2547	4.  Nursing home staff; assisted living facility staff;
2548	adult day care center staff; adult family-care home staff;
2549	social worker; or other professional adult care, residential, or
2550	institutional staff;
2551	5.  State, county, or municipal criminal justice employee
2552	or law enforcement officer;
2553	6.  An employee of the Department of Business and
2554	Professional Regulation conducting inspections of public lodging
2555	establishments under s. 509.032;
2556	7.  Florida advocacy council member or Long-term care
2557	ombudsman council member; or
2558	8.  Bank, savings and loan, or credit union officer,
2559	trustee, or employee,
2560
2561	who knows, or has reasonable cause to suspect, that a vulnerable
2562	adult has been or is being abused, neglected, or exploited shall
2563	immediately report such knowledge or suspicion to the central
2564	abuse hotline.
2565	Section 30.  Subsection (1) of section 415.104, Florida
2566	Statutes, is amended to read:
2567	415.104  Protective investigations of cases of abuse,
2568	neglect, or exploitation of vulnerable adults; transmittal of
2569	records to state attorney.--
2570	(1)  The department shall, upon receipt of a report
2571	alleging abuse, neglect, or exploitation of a vulnerable adult,
2572	begin within 24 hours a protective investigation of the facts
2573	alleged therein. If a caregiver refuses to allow the department
2574	to begin a protective investigation or interferes with the
2575	conduct of such an investigation, the appropriate law
2576	enforcement agency shall be contacted for assistance. If, during
2577	the course of the investigation, the department has reason to
2578	believe that the abuse, neglect, or exploitation is perpetrated
2579	by a second party, the appropriate law enforcement agency and
2580	state attorney shall be orally notified. The department and the
2581	law enforcement agency shall cooperate to allow the criminal
2582	investigation to proceed concurrently with, and not be hindered
2583	by, the protective investigation. The department shall make a
2584	preliminary written report to the law enforcement agencies
2585	within 5 working days after the oral report. The department
2586	shall, within 24 hours after receipt of the report, notify the
2587	appropriate Florida local advocacy council, or long-term care
2588	ombudsman council, when appropriate, that an alleged abuse,
2589	neglect, or exploitation perpetrated by a second party has
2590	occurred. Notice to the Florida local advocacy council or long-
2591	term care ombudsman council may be accomplished orally or in
2592	writing and shall include the name and location of the
2593	vulnerable adult alleged to have been abused, neglected, or
2594	exploited and the nature of the report.
2595	Section 31.  Subsection (8) of section 415.1055, Florida
2596	Statutes, is amended to read:
2597	415.1055  Notification to administrative entities.--
2598	(8)  At the conclusion of a protective investigation at a
2599	facility, the department shall notify either the Florida local
2600	advocacy council or long-term care ombudsman council of the
2601	results of the investigation. This notification must be in
2602	writing.
2603	Section 32.  Subsection (2) of section 415.106, Florida
2604	Statutes, is amended to read:
2605	415.106  Cooperation by the department and criminal justice
2606	and other agencies.--
2607	(2)  To ensure coordination, communication, and cooperation
2608	with the investigation of abuse, neglect, or exploitation of
2609	vulnerable adults, the department shall develop and maintain
2610	interprogram agreements or operational procedures among
2611	appropriate departmental programs and the State Long-Term Care
2612	Ombudsman Council, the Florida Statewide Advocacy Council, and
2613	other agencies that provide services to vulnerable adults. These
2614	agreements or procedures must cover such subjects as the
2615	appropriate roles and responsibilities of the department in
2616	identifying and responding to reports of abuse, neglect, or
2617	exploitation of vulnerable adults; the provision of services;
2618	and related coordinated activities.
2619	Section 33.  Paragraph (g) of subsection (3) of section
2620	415.107, Florida Statutes, is amended to read:
2621	415.107  Confidentiality of reports and records.--
2622	(3)  Access to all records, excluding the name of the
2623	reporter which shall be released only as provided in subsection
2624	(6), shall be granted only to the following persons, officials,
2625	and agencies:
2626	(g)  Any appropriate official of the Florida advocacy
2627	council or long-term care ombudsman council investigating a
2628	report of known or suspected abuse, neglect, or exploitation of
2629	a vulnerable adult.
2630	Section 34.  Subsection (9) of section 429.19, Florida
2631	Statutes, is amended to read:
2632	429.19  Violations; imposition of administrative fines;
2633	grounds.--
2634	(9)  The agency shall develop and disseminate an annual
2635	list of all facilities sanctioned or fined $5,000 or more for
2636	violations of state standards, the number and class of
2637	violations involved, the penalties imposed, and the current
2638	status of cases. The list shall be disseminated, at no charge,
2639	to the Department of Elderly Affairs, the Department of Health,
2640	the Department of Children and Family Services, the Agency for
2641	Persons with Disabilities, the area agencies on aging, the
2642	Florida Statewide Advocacy Council, and the state and local
2643	ombudsman councils. The Department of Children and Family
2644	Services shall disseminate the list to service providers under
2645	contract to the department who are responsible for referring
2646	persons to a facility for residency. The agency may charge a fee
2647	commensurate with the cost of printing and postage to other
2648	interested parties requesting a copy of this list.
2649	Section 35.  Subsection (2) of section 429.28, Florida
2650	Statutes, is amended to read:
2651	429.28  Resident bill of rights.--
2652	(2)  The administrator of a facility shall ensure that a
2653	written notice of the rights, obligations, and prohibitions set
2654	forth in this part is posted in a prominent place in each
2655	facility and read or explained to residents who cannot read.
2656	This notice shall include the name, address, and telephone
2657	numbers of the local ombudsman council and central abuse hotline
2658	and, when applicable, and the Advocacy Center for Persons with
2659	Disabilities, Inc., and the Florida local advocacy council,
2660	where complaints may be lodged. The facility must ensure a
2661	resident's access to a telephone to call the local ombudsman
2662	council, central abuse hotline, and the Advocacy Center for
2663	Persons with Disabilities, Inc., and the Florida local advocacy
2664	council.
2665	Section 36.  Section 429.34, Florida Statutes, is amended
2666	to read:
2667	429.34  Right of entry and inspection.--In addition to the
2668	requirements of s. 408.811, any duly designated officer or
2669	employee of the department, the Department of Children and
2670	Family Services, the Medicaid Fraud Control Unit of the Office
2671	of the Attorney General, the state or local fire marshal, or a
2672	member of the state or local long-term care ombudsman council
2673	shall have the right to enter unannounced upon and into the
2674	premises of any facility licensed pursuant to this part in order
2675	to determine the state of compliance with the provisions of this
2676	part, part II of chapter 408, and applicable rules. Data
2677	collected by the state or local long-term care ombudsman
2678	councils or the state or local advocacy councils may be used by
2679	the agency in investigations involving violations of regulatory
2680	standards.
2681	Section 37.  Subsection (3) of section 430.04, Florida
2682	Statutes, is amended to read:
2683	430.04  Duties and responsibilities of the Department of
2684	Elderly Affairs.--The Department of Elderly Affairs shall:
2685	(3)  Prepare and submit to the Governor, each Cabinet
2686	member, the President of the Senate, the Speaker of the House of
2687	Representatives, the minority leaders of the House and Senate,
2688	and chairpersons of appropriate House and Senate committees a
2689	master plan for policies and programs in the state related to
2690	aging. The plan must identify and assess the needs of the
2691	elderly population in the areas of housing, employment,
2692	education and training, medical care, long-term care, preventive
2693	care, protective services, social services, mental health,
2694	transportation, and long-term care insurance, and other areas
2695	considered appropriate by the department. The plan must assess
2696	the needs of particular subgroups of the population and evaluate
2697	the capacity of existing programs, both public and private and
2698	in state and local agencies, to respond effectively to
2699	identified needs. If the plan recommends the transfer of any
2700	program or service from the Department of Children and Family
2701	Services to another state department, the plan must also include
2702	recommendations that provide for an independent third-party
2703	mechanism, as currently exists in the Florida advocacy councils
2704	established in ss. 402.165 and 402.166, for protecting the
2705	constitutional and human rights of recipients of departmental
2706	services. The plan must include policy goals and program
2707	strategies designed to respond efficiently to current and
2708	projected needs. The plan must also include policy goals and
2709	program strategies to promote intergenerational relationships
2710	and activities. Public hearings and other appropriate processes
2711	shall be utilized by the department to solicit input for the
2712	development and updating of the master plan from parties
2713	including, but not limited to, the following:
2714	(a)  Elderly citizens and their families and caregivers.
2715	(b)  Local-level public and private service providers,
2716	advocacy organizations, and other organizations relating to the
2717	elderly.
2718	(c)  Local governments.
2719	(d)  All state agencies that provide services to the
2720	elderly.
2721	(e)  University centers on aging.
2722	(f)  Area agency on aging and community care for the
2723	elderly lead agencies.
2724	Section 38.  Sections 381.0271, 381.0273, 394.4595,
2725	402.164, 402.165, 402.166, 402.167, 409.9061, 430.80, 430.83,
2726	464.0195, 464.0196, 464.0197, and 464.0198, Florida Statutes,
2727	are repealed.
2728	Section 39.  This act shall take effect July 1, 2008.

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