HB 7109

A bill to be entitled
2An act relating to Medicaid; amending s. 393.0661, F.S.;
3requiring the Agency for Persons with Disabilities to
4establish a transition plan for current Medicaid
5recipients of home and community-based services under
6certain circumstances; providing for expiration of the
7section on a specified date; amending s. 393.0662, F.S.;
8requiring the Agency for Persons with Disabilities to
9complete the transition for current Medicaid recipients of
10home and community-based services to the iBudget system by
11a specified date; requiring the Agency for Persons with
12Disabilities to develop a transition plan for current
13Medicaid recipients of home and community-based services
14to managed care plans; providing for expiration of the
15section on a specified date; amending s. 408.040, F.S.;
16providing for suspension of certain conditions precedent
17to the issuance of a certificate of need for a nursing
18home, effective on a specified date; amending s. 408.0435,
19F.S.; extending the certificate-of-need moratorium for
20additional community nursing home beds; designating ss.
21409.016-409.803, F.S., as pt. I of ch. 409, F.S., and
22entitling the part "Social and Economic Assistance";
23designating ss. 409.810-409.821, F.S., as pt. II of ch.
24409, F.S., and entitling the part "Kidcare"; designating
25ss. 409.901-409.9205, F.S., as part III of ch. 409, F.S.,
26and entitling the part "Medicaid"; amending s. 409.905,
27F.S.; requiring the Agency for Health Care Administration
28to set reimbursements rates for hospitals that provide
29Medicaid services based on allowable-cost reporting from
30the hospitals; providing the methodology for the rate
31calculation and adjustments; requiring the rates to be
32subject to certain limits or ceilings; providing that
33exemptions to the limits or ceilings may be provided in
34the General Appropriations Act; deleting provisions
35relating to agency adjustments to a hospital's inpatient
36per diem rate; directing the agency to develop a plan to
37convert inpatient hospital rates to a prospective payment
38system that categorizes each case into diagnosis-related
39groups; requiring a report to the Governor and
40Legislature; amending s. 409.911, F.S.; providing for
41expiration of the Medicaid Low-Income Pool Council;
42amending s. 409.912, F.S.; providing payment requirements
43for provider service networks; providing for the
44expiration of various provisions relating to agency
45contracts and agreements with certain entities on
46specified dates to conform to the reorganization of
47Medicaid managed care; requiring the agency to contract on
48a prepaid or fixed-sum basis with certain prepaid dental
49health plans; eliminating obsolete provisions and updating
50provisions, to conform; amending ss. 409.91195 and
51409.91196, F.S.; conforming cross-references; repealing s.
52409.91207, F.S., relating to the medical home pilot
53project; amending s. 409.91211, F.S.; conforming cross-
54references; providing for future repeal of s. 409.91211,
55F.S., relating to the Medicaid managed care pilot program;
56amending s. 409.9122, F.S.; providing for the expiration
57of provisions relating to mandatory enrollment in a
58Medicaid managed care plan or MediPass on specified dates
59to conform to the reorganization of Medicaid managed care;
60eliminating obsolete provisions; requiring the agency to
61develop a process to enable any recipient with access to
62employer-sponsored coverage to opt out of eligible plans
63in the Medicaid program; requiring the agency, contingent
64on federal approval, to enable recipients with access to
65other coverage or related products that provide access to
66specified health care services to opt out of eligible
67plans in the Medicaid program; requiring the agency to
68maintain and operate the Medicaid Encounter Data System;
69requiring the agency to conduct a review of encounter data
70and publish the results of the review before adjusting
71rates for prepaid plans; authorizing the agency to
72establish a designated payment for specified Medicare
73Advantage Special Needs members; authorizing the agency to
74develop a designated payment for Medicaid-only covered
75services for which the state is responsible; requiring the
76agency to establish, and managed care plans to use, a
77uniform method of accounting for and reporting medical and
78nonmedical costs; authorizing the agency to create
79exceptions to mandatory enrollment in managed care under
80specified circumstances; requiring the agency to contract
81with a provider service network to function as a third-
82party administrator and managing entity for the MediPass
83program; providing contract provisions; providing for the
84expiration of such contract requirements on a specified
85date; amending s. 430.04, F.S.; eliminating obsolete
86provisions; requiring the Department of Elderly Affairs to
87develop a transition plan for specified elders and
88disabled adults receiving long-term care Medicaid services
89when eligible plans become available; providing for
90expiration of the plan; amending s. 430.2053, F.S.;
91eliminating obsolete provisions; providing additional
92duties of aging resource centers; providing an additional
93exception to direct services that may not be provided by
94an aging resource center; providing an expiration date for
95certain services administered through aging resource
96centers; providing for the cessation of specified payments
97by the department as eligible plans become available;
98providing for a memorandum of understanding between the
99agency and aging resource centers under certain
100circumstances; eliminating provisions requiring reports;
101repealing s. 430.701, F.S., relating to legislative
102findings and intent and approval for action relating to
103provider enrollment levels; repealing s. 430.702, F.S.,
104relating to the Long-Term Care Community Diversion Pilot
105Project Act; repealing s. 430.703, F.S., relating to
106definitions; repealing s. 430.7031, F.S., relating to the
107nursing home transition program; repealing s. 430.704,
108F.S., relating to evaluation of long-term care through the
109pilot projects; repealing s. 430.705, F.S., relating to
110implementation of long-term care community diversion pilot
111projects; repealing s. 430.706, F.S., relating to quality
112of care; repealing s. 430.707, F.S., relating to
113contracts; repealing s. 430.708, F.S., relating to
114certificate of need; repealing s. 430.709, F.S., relating
115to reports and evaluations; renumbering ss. 409.9301,
116409.942, 409.944, 409.945, 409.946, 409.953, and 409.9531,
117F.S., as ss. 402.81, 402.82, 402.83, 402.84, 402.85,
118402.86, and 402.87, F.S., respectively; amending ss.
119443.111 and 641.386, F.S.; conforming cross-references;
120directing the agency to develop a plan to implement the
121enrollment of the medically needy into managed care;
122providing effective dates and a contingent effective date.
124Be It Enacted by the Legislature of the State of Florida:
126     Section 1.  Section 393.0661, Florida Statutes, is amended
127to read:
128     393.0661  Home and community-based services delivery
129system; comprehensive redesign.-The Legislature finds that the
130home and community-based services delivery system for persons
131with developmental disabilities and the availability of
132appropriated funds are two of the critical elements in making
133services available. Therefore, it is the intent of the
134Legislature that the Agency for Persons with Disabilities shall
135develop and implement a comprehensive redesign of the system.
136     (1)  The redesign of the home and community-based services
137system shall include, at a minimum, all actions necessary to
138achieve an appropriate rate structure, client choice within a
139specified service package, appropriate assessment strategies, an
140efficient billing process that contains reconciliation and
141monitoring components, and a redefined role for support
142coordinators that avoids potential conflicts of interest and
143ensures that family/client budgets are linked to levels of need.
144     (a)  The agency shall use an assessment instrument that the
145agency deems to be reliable and valid, including, but not
146limited to, the Department of Children and Family Services'
147Individual Cost Guidelines or the agency's Questionnaire for
148Situational Information. The agency may contract with an
149external vendor or may use support coordinators to complete
150client assessments if it develops sufficient safeguards and
151training to ensure ongoing inter-rater reliability.
152     (b)  The agency, with the concurrence of the Agency for
153Health Care Administration, may contract for the determination
154of medical necessity and establishment of individual budgets.
155     (2)  A provider of services rendered to persons with
156developmental disabilities pursuant to a federally approved
157waiver shall be reimbursed according to a rate methodology based
158upon an analysis of the expenditure history and prospective
159costs of providers participating in the waiver program, or under
160any other methodology developed by the Agency for Health Care
161Administration, in consultation with the Agency for Persons with
162Disabilities, and approved by the Federal Government in
163accordance with the waiver.
164     (3)  The Agency for Health Care Administration, in
165consultation with the agency, shall seek federal approval and
166implement a four-tiered waiver system to serve eligible clients
167through the developmental disabilities and family and supported
168living waivers. The agency shall assign all clients receiving
169services through the developmental disabilities waiver to a tier
170based on the Department of Children and Family Services'
171Individual Cost Guidelines, the agency's Questionnaire for
172Situational Information, or another such assessment instrument
173deemed to be valid and reliable by the agency; client
174characteristics, including, but not limited to, age; and other
175appropriate assessment methods.
176     (a)  Tier one is limited to clients who have service needs
177that cannot be met in tier two, three, or four for intensive
178medical or adaptive needs and that are essential for avoiding
179institutionalization, or who possess behavioral problems that
180are exceptional in intensity, duration, or frequency and present
181a substantial risk of harm to themselves or others. Total annual
182expenditures under tier one may not exceed $150,000 per client
183each year, provided that expenditures for clients in tier one
184with a documented medical necessity requiring intensive
185behavioral residential habilitation services, intensive
186behavioral residential habilitation services with medical needs,
187or special medical home care, as provided in the Developmental
188Disabilities Waiver Services Coverage and Limitations Handbook,
189are not subject to the $150,000 limit on annual expenditures.
190     (b)  Tier two is limited to clients whose service needs
191include a licensed residential facility and who are authorized
192to receive a moderate level of support for standard residential
193habilitation services or a minimal level of support for behavior
194focus residential habilitation services, or clients in supported
195living who receive more than 6 hours a day of in-home support
196services. Total annual expenditures under tier two may not
197exceed $53,625 per client each year.
198     (c)  Tier three includes, but is not limited to, clients
199requiring residential placements, clients in independent or
200supported living situations, and clients who live in their
201family home. Total annual expenditures under tier three may not
202exceed $34,125 per client each year.
203     (d)  Tier four includes individuals who were enrolled in
204the family and supported living waiver on July 1, 2007, who
205shall be assigned to this tier without the assessments required
206by this section. Tier four also includes, but is not limited to,
207clients in independent or supported living situations and
208clients who live in their family home. Total annual expenditures
209under tier four may not exceed $14,422 per client each year.
210     (e)  The Agency for Health Care Administration shall also
211seek federal approval to provide a consumer-directed option for
212persons with developmental disabilities which corresponds to the
213funding levels in each of the waiver tiers. The agency shall
214implement the four-tiered waiver system beginning with tiers
215one, three, and four and followed by tier two. The agency and
216the Agency for Health Care Administration may adopt rules
217necessary to administer this subsection.
218     (f)  The agency shall seek federal waivers and amend
219contracts as necessary to make changes to services defined in
220federal waiver programs administered by the agency as follows:
221     1.  Supported living coaching services may not exceed 20
222hours per month for persons who also receive in-home support
224     2.  Limited support coordination services is the only type
225of support coordination service that may be provided to persons
226under the age of 18 who live in the family home.
227     3.  Personal care assistance services are limited to 180
228hours per calendar month and may not include rate modifiers.
229Additional hours may be authorized for persons who have
230intensive physical, medical, or adaptive needs if such hours are
231essential for avoiding institutionalization.
232     4.  Residential habilitation services are limited to 8
233hours per day. Additional hours may be authorized for persons
234who have intensive medical or adaptive needs and if such hours
235are essential for avoiding institutionalization, or for persons
236who possess behavioral problems that are exceptional in
237intensity, duration, or frequency and present a substantial risk
238of harming themselves or others. This restriction shall be in
239effect until the four-tiered waiver system is fully implemented.
240     5.  Chore services, nonresidential support services, and
241homemaker services are eliminated. The agency shall expand the
242definition of in-home support services to allow the service
243provider to include activities previously provided in these
244eliminated services.
245     6.  Massage therapy, medication review, and psychological
246assessment services are eliminated.
247     7.  The agency shall conduct supplemental cost plan reviews
248to verify the medical necessity of authorized services for plans
249that have increased by more than 8 percent during either of the
2502 preceding fiscal years.
251     8.  The agency shall implement a consolidated residential
252habilitation rate structure to increase savings to the state
253through a more cost-effective payment method and establish
254uniform rates for intensive behavioral residential habilitation
256     9.  Pending federal approval, the agency may extend current
257support plans for clients receiving services under Medicaid
258waivers for 1 year beginning July 1, 2007, or from the date
259approved, whichever is later. Clients who have a substantial
260change in circumstances which threatens their health and safety
261may be reassessed during this year in order to determine the
262necessity for a change in their support plan.
263     10.  The agency shall develop a plan to eliminate
264redundancies and duplications between in-home support services,
265companion services, personal care services, and supported living
266coaching by limiting or consolidating such services.
267     11.  The agency shall develop a plan to reduce the
268intensity and frequency of supported employment services to
269clients in stable employment situations who have a documented
270history of at least 3 years' employment with the same company or
271in the same industry.
272     (4)  The geographic differential for Miami-Dade, Broward,
273and Palm Beach Counties for residential habilitation services
274shall be 7.5 percent.
275     (5)  The geographic differential for Monroe County for
276residential habilitation services shall be 20 percent.
277     (6)  Effective January 1, 2010, and except as otherwise
278provided in this section, a client served by the home and
279community-based services waiver or the family and supported
280living waiver funded through the agency shall have his or her
281cost plan adjusted to reflect the amount of expenditures for the
282previous state fiscal year plus 5 percent if such amount is less
283than the client's existing cost plan. The agency shall use
284actual paid claims for services provided during the previous
285fiscal year that are submitted by October 31 to calculate the
286revised cost plan amount. If the client was not served for the
287entire previous state fiscal year or there was any single change
288in the cost plan amount of more than 5 percent during the
289previous state fiscal year, the agency shall set the cost plan
290amount at an estimated annualized expenditure amount plus 5
291percent. The agency shall estimate the annualized expenditure
292amount by calculating the average of monthly expenditures,
293beginning in the fourth month after the client enrolled,
294interrupted services are resumed, or the cost plan was changed
295by more than 5 percent and ending on August 31, 2009, and
296multiplying the average by 12. In order to determine whether a
297client was not served for the entire year, the agency shall
298include any interruption of a waiver-funded service or services
299lasting at least 18 days. If at least 3 months of actual
300expenditure data are not available to estimate annualized
301expenditures, the agency may not rebase a cost plan pursuant to
302this subsection. The agency may not rebase the cost plan of any
303client who experiences a significant change in recipient
304condition or circumstance which results in a change of more than
3055 percent to his or her cost plan between July 1 and the date
306that a rebased cost plan would take effect pursuant to this
308     (7)  Nothing in this section or in any administrative rule
309shall be construed to prevent or limit the Agency for Health
310Care Administration, in consultation with the Agency for Persons
311with Disabilities, from adjusting fees, reimbursement rates,
312lengths of stay, number of visits, or number of services, or
313from limiting enrollment, or making any other adjustment
314necessary to comply with the availability of moneys and any
315limitations or directions provided for in the General
316Appropriations Act.
317     (8)  The Agency for Persons with Disabilities shall submit
318quarterly status reports to the Executive Office of the
319Governor, the chair of the Senate Ways and Means Committee or
320its successor, and the chair of the House Fiscal Council or its
321successor regarding the financial status of home and community-
322based services, including the number of enrolled individuals who
323are receiving services through one or more programs; the number
324of individuals who have requested services who are not enrolled
325but who are receiving services through one or more programs,
326with a description indicating the programs from which the
327individual is receiving services; the number of individuals who
328have refused an offer of services but who choose to remain on
329the list of individuals waiting for services; the number of
330individuals who have requested services but who are receiving no
331services; a frequency distribution indicating the length of time
332individuals have been waiting for services; and information
333concerning the actual and projected costs compared to the amount
334of the appropriation available to the program and any projected
335surpluses or deficits. If at any time an analysis by the agency,
336in consultation with the Agency for Health Care Administration,
337indicates that the cost of services is expected to exceed the
338amount appropriated, the agency shall submit a plan in
339accordance with subsection (7) to the Executive Office of the
340Governor, the chair of the Senate Ways and Means Committee or
341its successor, and the chair of the House Fiscal Council or its
342successor to remain within the amount appropriated. The agency
343shall work with the Agency for Health Care Administration to
344implement the plan so as to remain within the appropriation.
345     (9)  The agency shall develop a transition plan for
346recipients who are receiving services in one of the four waiver
347tiers at the time eligible managed care plans are available in
348each recipient's region as defined in s. 409.989 to enroll those
349recipients in eligible plans.
350     (10)  This section expires October 1, 2016.
351     Section 2.  Section 393.0662, Florida Statutes, is amended
352to read:
353     393.0662  Individual budgets for delivery of home and
354community-based services; iBudget system established.-The
355Legislature finds that improved financial management of the
356existing home and community-based Medicaid waiver program is
357necessary to avoid deficits that impede the provision of
358services to individuals who are on the waiting list for
359enrollment in the program. The Legislature further finds that
360clients and their families should have greater flexibility to
361choose the services that best allow them to live in their
362community within the limits of an established budget. Therefore,
363the Legislature intends that the agency, in consultation with
364the Agency for Health Care Administration, develop and implement
365a comprehensive redesign of the service delivery system using
366individual budgets as the basis for allocating the funds
367appropriated for the home and community-based services Medicaid
368waiver program among eligible enrolled clients. The service
369delivery system that uses individual budgets shall be called the
370iBudget system.
371     (1)  The agency shall establish an individual budget,
372referred to as an iBudget, for each individual served by the
373home and community-based services Medicaid waiver program. The
374funds appropriated to the agency shall be allocated through the
375iBudget system to eligible, Medicaid-enrolled clients. The
376iBudget system shall be designed to provide for: enhanced client
377choice within a specified service package; appropriate
378assessment strategies; an efficient consumer budgeting and
379billing process that includes reconciliation and monitoring
380components; a redefined role for support coordinators that
381avoids potential conflicts of interest; a flexible and
382streamlined service review process; and a methodology and
383process that ensures the equitable allocation of available funds
384to each client based on the client's level of need, as
385determined by the variables in the allocation algorithm.
386     (a)  In developing each client's iBudget, the agency shall
387use an allocation algorithm and methodology. The algorithm shall
388use variables that have been determined by the agency to have a
389statistically validated relationship to the client's level of
390need for services provided through the home and community-based
391services Medicaid waiver program. The algorithm and methodology
392may consider individual characteristics, including, but not
393limited to, a client's age and living situation, information
394from a formal assessment instrument that the agency determines
395is valid and reliable, and information from other assessment
397     (b)  The allocation methodology shall provide the algorithm
398that determines the amount of funds allocated to a client's
399iBudget. The agency may approve an increase in the amount of
400funds allocated, as determined by the algorithm, based on the
401client having one or more of the following needs that cannot be
402accommodated within the funding as determined by the algorithm
403and having no other resources, supports, or services available
404to meet the need:
405     1.  An extraordinary need that would place the health and
406safety of the client, the client's caregiver, or the public in
407immediate, serious jeopardy unless the increase is approved. An
408extraordinary need may include, but is not limited to:
409     a.  A documented history of significant, potentially life-
410threatening behaviors, such as recent attempts at suicide,
411arson, nonconsensual sexual behavior, or self-injurious behavior
412requiring medical attention;
413     b.  A complex medical condition that requires active
414intervention by a licensed nurse on an ongoing basis that cannot
415be taught or delegated to a nonlicensed person;
416     c.  A chronic comorbid condition. As used in this
417subparagraph, the term "comorbid condition" means a medical
418condition existing simultaneously but independently with another
419medical condition in a patient; or
420     d.  A need for total physical assistance with activities
421such as eating, bathing, toileting, grooming, and personal
424However, the presence of an extraordinary need alone does not
425warrant an increase in the amount of funds allocated to a
426client's iBudget as determined by the algorithm.
427     2.  A significant need for one-time or temporary support or
428services that, if not provided, would place the health and
429safety of the client, the client's caregiver, or the public in
430serious jeopardy, unless the increase is approved. A significant
431need may include, but is not limited to, the provision of
432environmental modifications, durable medical equipment, services
433to address the temporary loss of support from a caregiver, or
434special services or treatment for a serious temporary condition
435when the service or treatment is expected to ameliorate the
436underlying condition. As used in this subparagraph, the term
437"temporary" means a period of fewer than 12 continuous months.
438However, the presence of such significant need for one-time or
439temporary supports or services alone does not warrant an
440increase in the amount of funds allocated to a client's iBudget
441as determined by the algorithm.
442     3.  A significant increase in the need for services after
443the beginning of the service plan year that would place the
444health and safety of the client, the client's caregiver, or the
445public in serious jeopardy because of substantial changes in the
446client's circumstances, including, but not limited to, permanent
447or long-term loss or incapacity of a caregiver, loss of services
448authorized under the state Medicaid plan due to a change in age,
449or a significant change in medical or functional status which
450requires the provision of additional services on a permanent or
451long-term basis that cannot be accommodated within the client's
452current iBudget. As used in this subparagraph, the term "long-
453term" means a period of 12 or more continuous months. However,
454such significant increase in need for services of a permanent or
455long-term nature alone does not warrant an increase in the
456amount of funds allocated to a client's iBudget as determined by
457the algorithm.
459The agency shall reserve portions of the appropriation for the
460home and community-based services Medicaid waiver program for
461adjustments required pursuant to this paragraph and may use the
462services of an independent actuary in determining the amount of
463the portions to be reserved.
464     (c)  A client's iBudget shall be the total of the amount
465determined by the algorithm and any additional funding provided
466pursuant to paragraph (b). A client's annual expenditures for
467home and community-based services Medicaid waiver services may
468not exceed the limits of his or her iBudget. The total of all
469clients' projected annual iBudget expenditures may not exceed
470the agency's appropriation for waiver services.
471     (2)  The Agency for Health Care Administration, in
472consultation with the agency, shall seek federal approval to
473amend current waivers, request a new waiver, and amend contracts
474as necessary to implement the iBudget system to serve eligible,
475enrolled clients through the home and community-based services
476Medicaid waiver program and the Consumer-Directed Care Plus
478     (3)  The agency shall transition all eligible, enrolled
479clients to the iBudget system. The agency may gradually phase in
480the iBudget system and must complete the phase in by January 1,
482     (a)  While the agency phases in the iBudget system, the
483agency may continue to serve eligible, enrolled clients under
484the four-tiered waiver system established under s. 393.065 while
485those clients await transitioning to the iBudget system.
486     (b)  The agency shall design the phase-in process to ensure
487that a client does not experience more than one-half of any
488expected overall increase or decrease to his or her existing
489annualized cost plan during the first year that the client is
490provided an iBudget due solely to the transition to the iBudget
492     (4)  A client must use all available services authorized
493under the state Medicaid plan, school-based services, private
494insurance and other benefits, and any other resources that may
495be available to the client before using funds from his or her
496iBudget to pay for support and services.
497     (5)  The service limitations in s. 393.0661(3)(f)1., 2.,
498and 3. do not apply to the iBudget system.
499     (6)  Rates for any or all services established under rules
500of the Agency for Health Care Administration shall be designated
501as the maximum rather than a fixed amount for individuals who
502receive an iBudget, except for services specifically identified
503in those rules that the agency determines are not appropriate
504for negotiation, which may include, but are not limited to,
505residential habilitation services.
506     (7)  The agency shall ensure that clients and caregivers
507have access to training and education to inform them about the
508iBudget system and enhance their ability for self-direction.
509Such training shall be offered in a variety of formats and at a
510minimum shall address the policies and processes of the iBudget
511system; the roles and responsibilities of consumers, caregivers,
512waiver support coordinators, providers, and the agency;
513information available to help the client make decisions
514regarding the iBudget system; and examples of support and
515resources available in the community.
516     (8)  The agency shall collect data to evaluate the
517implementation and outcomes of the iBudget system.
518     (9)  The agency and the Agency for Health Care
519Administration may adopt rules specifying the allocation
520algorithm and methodology; criteria and processes for clients to
521access reserved funds for extraordinary needs, temporarily or
522permanently changed needs, and one-time needs; and processes and
523requirements for selection and review of services, development
524of support and cost plans, and management of the iBudget system
525as needed to administer this section.
526     (10)  The agency shall develop a transition plan for
527recipients who are receiving services through the iBudget system
528at the time eligible managed care plans are available in each
529recipient's region defined in s. 409.989 to enroll those
530recipients in eligible plans.
531     (11)  This section expires October 1, 2016.
532     Section 3.  Paragraph (e) of subsection (1) of section
533408.040, Florida Statutes, is redesignated as paragraph (d), and
534paragraph (b) and present paragraph (d) of that subsection are
535amended to read:
536     408.040  Conditions and monitoring.-
537     (1)
538     (b)  The agency may consider, in addition to the other
539criteria specified in s. 408.035, a statement of intent by the
540applicant that a specified percentage of the annual patient days
541at the facility will be utilized by patients eligible for care
542under Title XIX of the Social Security Act. Any certificate of
543need issued to a nursing home in reliance upon an applicant's
544statements that a specified percentage of annual patient days
545will be utilized by residents eligible for care under Title XIX
546of the Social Security Act must include a statement that such
547certification is a condition of issuance of the certificate of
548need. The certificate-of-need program shall notify the Medicaid
549program office and the Department of Elderly Affairs when it
550imposes conditions as authorized in this paragraph in an area in
551which a community diversion pilot project is implemented.
552Effective July 1, 2012, the agency may not consider, or impose
553conditions or sanctions related to, patient day utilization by
554patients eligible for care under Title XIX the Social Security
555Act in making certificate-of-need determinations for nursing
557     (d)  If a nursing home is located in a county in which a
558long-term care community diversion pilot project has been
559implemented under s. 430.705 or in a county in which an
560integrated, fixed-payment delivery program for Medicaid
561recipients who are 60 years of age or older or dually eligible
562for Medicare and Medicaid has been implemented under s.
563409.912(5), the nursing home may request a reduction in the
564percentage of annual patient days used by residents who are
565eligible for care under Title XIX of the Social Security Act,
566which is a condition of the nursing home's certificate of need.
567The agency shall automatically grant the nursing home's request
568if the reduction is not more than 15 percent of the nursing
569home's annual Medicaid-patient-days condition. A nursing home
570may submit only one request every 2 years for an automatic
571reduction. A requesting nursing home must notify the agency in
572writing at least 60 days in advance of its intent to reduce its
573annual Medicaid-patient-days condition by not more than 15
574percent. The agency must acknowledge the request in writing and
575must change its records to reflect the revised certificate-of-
576need condition. This paragraph expires June 30, 2011.
577     Section 4.  Subsection (1) of section 408.0435, Florida
578Statutes, is amended to read:
579     408.0435  Moratorium on nursing home certificates of need.-
580     (1)  Notwithstanding the establishment of need as provided
581for in this chapter, a certificate of need for additional
582community nursing home beds may not be approved by the agency
583until Medicaid managed care is implemented statewide pursuant to
584ss. 409.961-409.992 or October 1, 2016, whichever is earlier
585July 1, 2011.
586     Section 5.  Sections 409.016 through 409.803, Florida
587Statutes, are designated as part I of chapter 409, Florida
588Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
589     Section 6.  Sections 409.810 through 409.821, Florida
590Statutes, are designated as part II of chapter 409, Florida
591Statutes, and entitled "KIDCARE."
592     Section 7.  Sections 409.901 through 409.9205, Florida
593Statutes, are designated as part III of chapter 409, Florida
594Statutes, and entitled "MEDICAID."
595     Section 8.  Paragraph (c) of subsection (5) of section
596409.905, Florida Statutes, is amended, and paragraph (g) is
597added that subsection, to read:
598     409.905  Mandatory Medicaid services.-The agency may make
599payments for the following services, which are required of the
600state by Title XIX of the Social Security Act, furnished by
601Medicaid providers to recipients who are determined to be
602eligible on the dates on which the services were provided. Any
603service under this section shall be provided only when medically
604necessary and in accordance with state and federal law.
605Mandatory services rendered by providers in mobile units to
606Medicaid recipients may be restricted by the agency. Nothing in
607this section shall be construed to prevent or limit the agency
608from adjusting fees, reimbursement rates, lengths of stay,
609number of visits, number of services, or any other adjustments
610necessary to comply with the availability of moneys and any
611limitations or directions provided for in the General
612Appropriations Act or chapter 216.
613     (5)  HOSPITAL INPATIENT SERVICES.-The agency shall pay for
614all covered services provided for the medical care and treatment
615of a recipient who is admitted as an inpatient by a licensed
616physician or dentist to a hospital licensed under part I of
617chapter 395. However, the agency shall limit the payment for
618inpatient hospital services for a Medicaid recipient 21 years of
619age or older to 45 days or the number of days necessary to
620comply with the General Appropriations Act.
621     (c)  The agency shall implement a methodology for
622establishing base reimbursement rates for each hospital based on
623allowable costs, as defined by the agency. Rates shall be
624calculated annually and take effect July 1 of each year based on
625the most recent complete and accurate cost report submitted by
626each hospital. Adjustments may not be made to the rates after
627September 30 of the state fiscal year in which the rate takes
628effect. Errors in cost reporting or calculation of rates
629discovered after September 30 must be reconciled in a subsequent
630rate period. Cost reports must be reconciled within 5 years
631after the end of the applicable fiscal year. Hospital rates
632shall be subject to such limits or ceilings as may be
633established in law or described in the agency's hospital
634reimbursement plan. Specific exemptions to the limits or
635ceilings may be provided in the General Appropriations Act. The
636agency shall adjust a hospital's current inpatient per diem rate
637to reflect the cost of serving the Medicaid population at that
638institution if:
639     1.  The hospital experiences an increase in Medicaid
640caseload by more than 25 percent in any year, primarily
641resulting from the closure of a hospital in the same service
642area occurring after July 1, 1995;
643     2.  The hospital's Medicaid per diem rate is at least 25
644percent below the Medicaid per patient cost for that year; or
645     3.  The hospital is located in a county that has six or
646fewer general acute care hospitals, began offering obstetrical
647services on or after September 1999, and has submitted a request
648in writing to the agency for a rate adjustment after July 1,
6492000, but before September 30, 2000, in which case such
650hospital's Medicaid inpatient per diem rate shall be adjusted to
651cost, effective July 1, 2002.
653By October 1 of each year, the agency must provide estimated
654costs for any adjustment in a hospital inpatient per diem rate
655to the Executive Office of the Governor, the House of
656Representatives General Appropriations Committee, and the Senate
657Appropriations Committee. Before the agency implements a change
658in a hospital's inpatient per diem rate pursuant to this
659paragraph, the Legislature must have specifically appropriated
660sufficient funds in the General Appropriations Act to support
661the increase in cost as estimated by the agency.
662     (g)  The agency shall develop a plan to convert inpatient
663hospital rates to a prospective payment system that categorizes
664each case into diagnosis-related groups (DRG) and assigns a
665payment weight based on the average resources used to treat
666Medicaid patients in that DRG. To the extent possible, the
667agency shall propose an adaptation of an existing prospective
668payment system, such as the one used by Medicare, and shall
669propose such adjustments as are necessary for the Medicaid
670population and to maintain budget neutrality for inpatient
671hospital expenditures. The agency shall submit the Medicaid DRG
672plan, identifying all steps necessary for the transition and any
673costs associated with plan implementation, to the Governor, the
674President of the Senate, and the Speaker of the House of
675Representatives no later than January 1, 2013.
676     Section 9.  Subsection (10) of section 409.911, Florida
677Statutes, is amended to read:
678     409.911  Disproportionate share program.-Subject to
679specific allocations established within the General
680Appropriations Act and any limitations established pursuant to
681chapter 216, the agency shall distribute, pursuant to this
682section, moneys to hospitals providing a disproportionate share
683of Medicaid or charity care services by making quarterly
684Medicaid payments as required. Notwithstanding the provisions of
685s. 409.915, counties are exempt from contributing toward the
686cost of this special reimbursement for hospitals serving a
687disproportionate share of low-income patients.
688     (10)  The Agency for Health Care Administration shall
689create a Medicaid Low-Income Pool Council by July 1, 2006. The
690Low-Income Pool Council shall consist of 24 members, including 2
691members appointed by the President of the Senate, 2 members
692appointed by the Speaker of the House of Representatives, 3
693representatives of statutory teaching hospitals, 3
694representatives of public hospitals, 3 representatives of
695nonprofit hospitals, 3 representatives of for-profit hospitals,
6962 representatives of rural hospitals, 2 representatives of units
697of local government which contribute funding, 1 representative
698of family practice teaching hospitals, 1 representative of
699federally qualified health centers, 1 representative from the
700Department of Health, and 1 nonvoting representative of the
701Agency for Health Care Administration who shall serve as chair
702of the council. Except for a full-time employee of a public
703entity, an individual who qualifies as a lobbyist under s.
70411.045 or s. 112.3215 may not serve as a member of the council.
705Of the members appointed by the Senate President, only one shall
706be a physician. Of the members appointed by the Speaker of the
707House of Representatives, only one shall be a physician. The
708physician member appointed by the Senate President and the
709physician member appointed by the Speaker of the House of
710Representatives must be physicians who routinely take calls in a
711trauma center, as defined in s. 395.4001, or a hospital
712emergency department. The council shall:
713     (a)  Make recommendations on the financing of the low-
714income pool and the disproportionate share hospital program and
715the distribution of their funds.
716     (b)  Advise the Agency for Health Care Administration on
717the development of the low-income pool plan required by the
718federal Centers for Medicare and Medicaid Services pursuant to
719the Medicaid reform waiver.
720     (c)  Advise the Agency for Health Care Administration on
721the distribution of hospital funds used to adjust inpatient
722hospital rates, rebase rates, or otherwise exempt hospitals from
723reimbursement limits as financed by intergovernmental transfers.
724     (d)  Submit its findings and recommendations to the
725Governor and the Legislature no later than February 1 of each
728This subsection expires October 1, 2014.
729     Section 10.  Subsection (4) of section 409.91195, Florida
730Statutes, is amended to read:
731     409.91195  Medicaid Pharmaceutical and Therapeutics
732Committee.-There is created a Medicaid Pharmaceutical and
733Therapeutics Committee within the agency for the purpose of
734developing a Medicaid preferred drug list.
735     (4)  Upon recommendation of the committee, the agency shall
736adopt a preferred drug list as described in s. 409.912(37)(39).
737To the extent feasible, the committee shall review all drug
738classes included on the preferred drug list every 12 months, and
739may recommend additions to and deletions from the preferred drug
740list, such that the preferred drug list provides for medically
741appropriate drug therapies for Medicaid patients which achieve
742cost savings contained in the General Appropriations Act.
743     Section 11.  Subsection (1) of section 409.91196, Florida
744Statutes, is amended to read:
745     409.91196  Supplemental rebate agreements; public records
746and public meetings exemption.-
747     (1)  The rebate amount, percent of rebate, manufacturer's
748pricing, and supplemental rebate, and other trade secrets as
749defined in s. 688.002 that the agency has identified for use in
750negotiations, held by the Agency for Health Care Administration
751under s. 409.912(37)(39)(a)7. are confidential and exempt from
752s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
753     Section 12.  Section 409.912, Florida Statutes, is amended
754to read:
755     409.912  Cost-effective purchasing of health care.-The
756agency shall purchase goods and services for Medicaid recipients
757in the most cost-effective manner consistent with the delivery
758of quality medical care. To ensure that medical services are
759effectively utilized, the agency may, in any case, require a
760confirmation or second physician's opinion of the correct
761diagnosis for purposes of authorizing future services under the
762Medicaid program. This section does not restrict access to
763emergency services or poststabilization care services as defined
764in 42 C.F.R. part 438.114. Such confirmation or second opinion
765shall be rendered in a manner approved by the agency. The agency
766shall maximize the use of prepaid per capita and prepaid
767aggregate fixed-sum basis services when appropriate and other
768alternative service delivery and reimbursement methodologies,
769including competitive bidding pursuant to s. 287.057, designed
770to facilitate the cost-effective purchase of a case-managed
771continuum of care. The agency shall also require providers to
772minimize the exposure of recipients to the need for acute
773inpatient, custodial, and other institutional care and the
774inappropriate or unnecessary use of high-cost services. The
775agency shall contract with a vendor to monitor and evaluate the
776clinical practice patterns of providers in order to identify
777trends that are outside the normal practice patterns of a
778provider's professional peers or the national guidelines of a
779provider's professional association. The vendor must be able to
780provide information and counseling to a provider whose practice
781patterns are outside the norms, in consultation with the agency,
782to improve patient care and reduce inappropriate utilization.
783The agency may mandate prior authorization, drug therapy
784management, or disease management participation for certain
785populations of Medicaid beneficiaries, certain drug classes, or
786particular drugs to prevent fraud, abuse, overuse, and possible
787dangerous drug interactions. The Pharmaceutical and Therapeutics
788Committee shall make recommendations to the agency on drugs for
789which prior authorization is required. The agency shall inform
790the Pharmaceutical and Therapeutics Committee of its decisions
791regarding drugs subject to prior authorization. The agency is
792authorized to limit the entities it contracts with or enrolls as
793Medicaid providers by developing a provider network through
794provider credentialing. The agency may competitively bid single-
795source-provider contracts if procurement of goods or services
796results in demonstrated cost savings to the state without
797limiting access to care. The agency may limit its network based
798on the assessment of beneficiary access to care, provider
799availability, provider quality standards, time and distance
800standards for access to care, the cultural competence of the
801provider network, demographic characteristics of Medicaid
802beneficiaries, practice and provider-to-beneficiary standards,
803appointment wait times, beneficiary use of services, provider
804turnover, provider profiling, provider licensure history,
805previous program integrity investigations and findings, peer
806review, provider Medicaid policy and billing compliance records,
807clinical and medical record audits, and other factors. Providers
808are shall not be entitled to enrollment in the Medicaid provider
809network. The agency shall determine instances in which allowing
810Medicaid beneficiaries to purchase durable medical equipment and
811other goods is less expensive to the Medicaid program than long-
812term rental of the equipment or goods. The agency may establish
813rules to facilitate purchases in lieu of long-term rentals in
814order to protect against fraud and abuse in the Medicaid program
815as defined in s. 409.913. The agency may seek federal waivers
816necessary to administer these policies.
817     (1)  The agency shall work with the Department of Children
818and Family Services to ensure access of children and families in
819the child protection system to needed and appropriate mental
820health and substance abuse services. This subsection expires
821October 1, 2014.
822     (2)  The agency may enter into agreements with appropriate
823agents of other state agencies or of any agency of the Federal
824Government and accept such duties in respect to social welfare
825or public aid as may be necessary to implement the provisions of
826Title XIX of the Social Security Act and ss. 409.901-409.920.
827This subsection expires October 1, 2016.
828     (3)  The agency may contract with health maintenance
829organizations certified pursuant to part I of chapter 641 for
830the provision of services to recipients. This subsection expires
831October 1, 2014.
832     (4)  The agency may contract with:
833     (a)  An entity that provides no prepaid health care
834services other than Medicaid services under contract with the
835agency and which is owned and operated by a county, county
836health department, or county-owned and operated hospital to
837provide health care services on a prepaid or fixed-sum basis to
838recipients, which entity may provide such prepaid services
839either directly or through arrangements with other providers.
840Such prepaid health care services entities must be licensed
841under parts I and III of chapter 641. An entity recognized under
842this paragraph which demonstrates to the satisfaction of the
843Office of Insurance Regulation of the Financial Services
844Commission that it is backed by the full faith and credit of the
845county in which it is located may be exempted from s. 641.225.
846This paragraph expires October 1, 2014.
847     (b)  An entity that is providing comprehensive behavioral
848health care services to certain Medicaid recipients through a
849capitated, prepaid arrangement pursuant to the federal waiver
850provided for by s. 409.905(5). Such entity must be licensed
851under chapter 624, chapter 636, or chapter 641, or authorized
852under paragraph (c) or paragraph (d), and must possess the
853clinical systems and operational competence to manage risk and
854provide comprehensive behavioral health care to Medicaid
855recipients. As used in this paragraph, the term "comprehensive
856behavioral health care services" means covered mental health and
857substance abuse treatment services that are available to
858Medicaid recipients. The secretary of the Department of Children
859and Family Services shall approve provisions of procurements
860related to children in the department's care or custody before
861enrolling such children in a prepaid behavioral health plan. Any
862contract awarded under this paragraph must be competitively
863procured. In developing the behavioral health care prepaid plan
864procurement document, the agency shall ensure that the
865procurement document requires the contractor to develop and
866implement a plan to ensure compliance with s. 394.4574 related
867to services provided to residents of licensed assisted living
868facilities that hold a limited mental health license. Except as
869provided in subparagraph 5. 8., and except in counties where the
870Medicaid managed care pilot program is authorized pursuant to s.
871409.91211, the agency shall seek federal approval to contract
872with a single entity meeting these requirements to provide
873comprehensive behavioral health care services to all Medicaid
874recipients not enrolled in a Medicaid managed care plan
875authorized under s. 409.91211, a provider service network
876authorized under paragraph (d), or a Medicaid health maintenance
877organization in an AHCA area. In an AHCA area where the Medicaid
878managed care pilot program is authorized pursuant to s.
879409.91211 in one or more counties, the agency may procure a
880contract with a single entity to serve the remaining counties as
881an AHCA area or the remaining counties may be included with an
882adjacent AHCA area and are subject to this paragraph. Each
883entity must offer a sufficient choice of providers in its
884network to ensure recipient access to care and the opportunity
885to select a provider with whom they are satisfied. The network
886shall include all public mental health hospitals. To ensure
887unimpaired access to behavioral health care services by Medicaid
888recipients, all contracts issued pursuant to this paragraph must
889require 80 percent of the capitation paid to the managed care
890plan, including health maintenance organizations and capitated
891provider service networks, to be expended for the provision of
892behavioral health care services. If the managed care plan
893expends less than 80 percent of the capitation paid for the
894provision of behavioral health care services, the difference
895shall be returned to the agency. The agency shall provide the
896plan with a certification letter indicating the amount of
897capitation paid during each calendar year for behavioral health
898care services pursuant to this section. The agency may reimburse
899for substance abuse treatment services on a fee-for-service
900basis until the agency finds that adequate funds are available
901for capitated, prepaid arrangements.
902     1.  By January 1, 2001, The agency shall modify the
903contracts with the entities providing comprehensive inpatient
904and outpatient mental health care services to Medicaid
905recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
906Counties, to include substance abuse treatment services.
907     2.  By July 1, 2003, the agency and the Department of
908Children and Family Services shall execute a written agreement
909that requires collaboration and joint development of all policy,
910budgets, procurement documents, contracts, and monitoring plans
911that have an impact on the state and Medicaid community mental
912health and targeted case management programs.
913     2.3.  Except as provided in subparagraph 5. 8., by July 1,
9142006, the agency and the Department of Children and Family
915Services shall contract with managed care entities in each AHCA
916area except area 6 or arrange to provide comprehensive inpatient
917and outpatient mental health and substance abuse services
918through capitated prepaid arrangements to all Medicaid
919recipients who are eligible to participate in such plans under
920federal law and regulation. In AHCA areas where eligible
921individuals number less than 150,000, the agency shall contract
922with a single managed care plan to provide comprehensive
923behavioral health services to all recipients who are not
924enrolled in a Medicaid health maintenance organization, a
925provider service network authorized under paragraph (d), or a
926Medicaid capitated managed care plan authorized under s.
927409.91211. The agency may contract with more than one
928comprehensive behavioral health provider to provide care to
929recipients who are not enrolled in a Medicaid capitated managed
930care plan authorized under s. 409.91211, a provider service
931network authorized under paragraph (d), or a Medicaid health
932maintenance organization in AHCA areas where the eligible
933population exceeds 150,000. In an AHCA area where the Medicaid
934managed care pilot program is authorized pursuant to s.
935409.91211 in one or more counties, the agency may procure a
936contract with a single entity to serve the remaining counties as
937an AHCA area or the remaining counties may be included with an
938adjacent AHCA area and shall be subject to this paragraph.
939Contracts for comprehensive behavioral health providers awarded
940pursuant to this section shall be competitively procured. Both
941for-profit and not-for-profit corporations are eligible to
942compete. Managed care plans contracting with the agency under
943subsection (3) or paragraph (d), shall provide and receive
944payment for the same comprehensive behavioral health benefits as
945provided in AHCA rules, including handbooks incorporated by
946reference. In AHCA area 11, the agency shall contract with at
947least two comprehensive behavioral health care providers to
948provide behavioral health care to recipients in that area who
949are enrolled in, or assigned to, the MediPass program. One of
950the behavioral health care contracts must be with the existing
951provider service network pilot project, as described in
952paragraph (d), for the purpose of demonstrating the cost-
953effectiveness of the provision of quality mental health services
954through a public hospital-operated managed care model. Payment
955shall be at an agreed-upon capitated rate to ensure cost
956savings. Of the recipients in area 11 who are assigned to
957MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
958MediPass-enrolled recipients shall be assigned to the existing
959provider service network in area 11 for their behavioral care.
960     4.  By October 1, 2003, the agency and the department shall
961submit a plan to the Governor, the President of the Senate, and
962the Speaker of the House of Representatives which provides for
963the full implementation of capitated prepaid behavioral health
964care in all areas of the state.
965     a.  Implementation shall begin in 2003 in those AHCA areas
966of the state where the agency is able to establish sufficient
967capitation rates.
968     b.  If the agency determines that the proposed capitation
969rate in any area is insufficient to provide appropriate
970services, the agency may adjust the capitation rate to ensure
971that care will be available. The agency and the department may
972use existing general revenue to address any additional required
973match but may not over-obligate existing funds on an annualized
975     c.  Subject to any limitations provided in the General
976Appropriations Act, the agency, in compliance with appropriate
977federal authorization, shall develop policies and procedures
978that allow for certification of local and state funds.
979     3.5.  Children residing in a statewide inpatient
980psychiatric program, or in a Department of Juvenile Justice or a
981Department of Children and Family Services residential program
982approved as a Medicaid behavioral health overlay services
983provider may not be included in a behavioral health care prepaid
984health plan or any other Medicaid managed care plan pursuant to
985this paragraph.
986     6.  In converting to a prepaid system of delivery, the
987agency shall in its procurement document require an entity
988providing only comprehensive behavioral health care services to
989prevent the displacement of indigent care patients by enrollees
990in the Medicaid prepaid health plan providing behavioral health
991care services from facilities receiving state funding to provide
992indigent behavioral health care, to facilities licensed under
993chapter 395 which do not receive state funding for indigent
994behavioral health care, or reimburse the unsubsidized facility
995for the cost of behavioral health care provided to the displaced
996indigent care patient.
997     4.7.  Traditional community mental health providers under
998contract with the Department of Children and Family Services
999pursuant to part IV of chapter 394, child welfare providers
1000under contract with the Department of Children and Family
1001Services in areas 1 and 6, and inpatient mental health providers
1002licensed pursuant to chapter 395 must be offered an opportunity
1003to accept or decline a contract to participate in any provider
1004network for prepaid behavioral health services.
1005     5.8.  All Medicaid-eligible children, except children in
1006area 1 and children in Highlands County, Hardee County, Polk
1007County, or Manatee County of area 6, that are open for child
1008welfare services in the HomeSafeNet system, shall receive their
1009behavioral health care services through a specialty prepaid plan
1010operated by community-based lead agencies through a single
1011agency or formal agreements among several agencies. The
1012specialty prepaid plan must result in savings to the state
1013comparable to savings achieved in other Medicaid managed care
1014and prepaid programs. Such plan must provide mechanisms to
1015maximize state and local revenues. The specialty prepaid plan
1016shall be developed by the agency and the Department of Children
1017and Family Services. The agency may seek federal waivers to
1018implement this initiative. Medicaid-eligible children whose
1019cases are open for child welfare services in the HomeSafeNet
1020system and who reside in AHCA area 10 are exempt from the
1021specialty prepaid plan upon the development of a service
1022delivery mechanism for children who reside in area 10 as
1023specified in s. 409.91211(3)(dd).
1025This paragraph expires October 1, 2014.
1026     (c)  A federally qualified health center or an entity owned
1027by one or more federally qualified health centers or an entity
1028owned by other migrant and community health centers receiving
1029non-Medicaid financial support from the Federal Government to
1030provide health care services on a prepaid or fixed-sum basis to
1031recipients. A federally qualified health center or an entity
1032that is owned by one or more federally qualified health centers
1033and is reimbursed by the agency on a prepaid basis is exempt
1034from parts I and III of chapter 641, but must comply with the
1035solvency requirements in s. 641.2261(2) and meet the appropriate
1036requirements governing financial reserve, quality assurance, and
1037patients' rights established by the agency. This paragraph
1038expires October 1, 2014.
1039     (d)1.  A provider service network may be reimbursed on a
1040fee-for-service or prepaid basis. Prepaid provider service
1041networks shall receive per-member, per-month payments. A
1042provider service network that does not choose to be a prepaid
1043plan shall receive fee-for-service rates with a shared savings
1044settlement. The fee-for-service option shall be available to a
1045provider service network only for the first 5 years of the
1046plan's operation or until the contract year beginning October 1,
10472014, whichever is later. The agency shall annually conduct cost
1048reconciliations to determine the amount of cost savings achieved
1049by fee-for-service provider service networks for the dates of
1050service in the period being reconciled. Only payments for
1051covered services for dates of service within the reconciliation
1052period and paid within 6 months after the last date of service
1053in the reconciliation period shall be included. The agency shall
1054perform the necessary adjustments for the inclusion of claims
1055incurred but not reported within the reconciliation for claims
1056that could be received and paid by the agency after the 6-month
1057claims processing time lag. The agency shall provide the results
1058of the reconciliations to the fee-for-service provider service
1059networks within 45 days after the end of the reconciliation
1060period. The fee-for-service provider service networks shall
1061review and provide written comments or a letter of concurrence
1062to the agency within 45 days after receipt of the reconciliation
1063results. This reconciliation shall be considered final.
1064     2.  A provider service network which is reimbursed by the
1065agency on a prepaid basis shall be exempt from parts I and III
1066of chapter 641, but must comply with the solvency requirements
1067in s. 641.2261(2) and meet appropriate financial reserve,
1068quality assurance, and patient rights requirements as
1069established by the agency.
1070     3.  Medicaid recipients assigned to a provider service
1071network shall be chosen equally from those who would otherwise
1072have been assigned to prepaid plans and MediPass. The agency is
1073authorized to seek federal Medicaid waivers as necessary to
1074implement the provisions of this section. This subparagraph
1075expires October 1, 2014. Any contract previously awarded to a
1076provider service network operated by a hospital pursuant to this
1077subsection shall remain in effect for a period of 3 years
1078following the current contract expiration date, regardless of
1079any contractual provisions to the contrary.
1080     4.  A provider service network is a network established or
1081organized and operated by a health care provider, or group of
1082affiliated health care providers, including minority physician
1083networks and emergency room diversion programs that meet the
1084requirements of s. 409.91211, which provides a substantial
1085proportion of the health care items and services under a
1086contract directly through the provider or affiliated group of
1087providers and may make arrangements with physicians or other
1088health care professionals, health care institutions, or any
1089combination of such individuals or institutions to assume all or
1090part of the financial risk on a prospective basis for the
1091provision of basic health services by the physicians, by other
1092health professionals, or through the institutions. The health
1093care providers must have a controlling interest in the governing
1094body of the provider service network organization.
1095     (e)  An entity that provides only comprehensive behavioral
1096health care services to certain Medicaid recipients through an
1097administrative services organization agreement. Such an entity
1098must possess the clinical systems and operational competence to
1099provide comprehensive health care to Medicaid recipients. As
1100used in this paragraph, the term "comprehensive behavioral
1101health care services" means covered mental health and substance
1102abuse treatment services that are available to Medicaid
1103recipients. Any contract awarded under this paragraph must be
1104competitively procured. The agency must ensure that Medicaid
1105recipients have available the choice of at least two managed
1106care plans for their behavioral health care services. This
1107paragraph expires October 1, 2014.
1108     (f)  An entity that provides in-home physician services to
1109test the cost-effectiveness of enhanced home-based medical care
1110to Medicaid recipients with degenerative neurological diseases
1111and other diseases or disabling conditions associated with high
1112costs to Medicaid. The program shall be designed to serve very
1113disabled persons and to reduce Medicaid reimbursed costs for
1114inpatient, outpatient, and emergency department services. The
1115agency shall contract with vendors on a risk-sharing basis.
1116     (g)  Children's provider networks that provide care
1117coordination and care management for Medicaid-eligible pediatric
1118patients, primary care, authorization of specialty care, and
1119other urgent and emergency care through organized providers
1120designed to service Medicaid eligibles under age 18 and
1121pediatric emergency departments' diversion programs. The
1122networks shall provide after-hour operations, including evening
1123and weekend hours, to promote, when appropriate, the use of the
1124children's networks rather than hospital emergency departments.
1125     (f)(h)  An entity authorized in s. 430.205 to contract with
1126the agency and the Department of Elderly Affairs to provide
1127health care and social services on a prepaid or fixed-sum basis
1128to elderly recipients. Such prepaid health care services
1129entities are exempt from the provisions of part I of chapter 641
1130for the first 3 years of operation. An entity recognized under
1131this paragraph that demonstrates to the satisfaction of the
1132Office of Insurance Regulation that it is backed by the full
1133faith and credit of one or more counties in which it operates
1134may be exempted from s. 641.225. This paragraph expires October
11351, 2013.
1136     (g)(i)  A Children's Medical Services Network, as defined
1137in s. 391.021. This paragraph expires October 1, 2014.
1138     (5)  The Agency for Health Care Administration, in
1139partnership with the Department of Elderly Affairs, shall create
1140an integrated, fixed-payment delivery program for Medicaid
1141recipients who are 60 years of age or older or dually eligible
1142for Medicare and Medicaid. The Agency for Health Care
1143Administration shall implement the integrated program initially
1144on a pilot basis in two areas of the state. The pilot areas
1145shall be Area 7 and Area 11 of the Agency for Health Care
1146Administration. Enrollment in the pilot areas shall be on a
1147voluntary basis and in accordance with approved federal waivers
1148and this section. The agency and its program contractors and
1149providers shall not enroll any individual in the integrated
1150program because the individual or the person legally responsible
1151for the individual fails to choose to enroll in the integrated
1152program. Enrollment in the integrated program shall be
1153exclusively by affirmative choice of the eligible individual or
1154by the person legally responsible for the individual. The
1155integrated program must transfer all Medicaid services for
1156eligible elderly individuals who choose to participate into an
1157integrated-care management model designed to serve Medicaid
1158recipients in the community. The integrated program must combine
1159all funding for Medicaid services provided to individuals who
1160are 60 years of age or older or dually eligible for Medicare and
1161Medicaid into the integrated program, including funds for
1162Medicaid home and community-based waiver services; all Medicaid
1163services authorized in ss. 409.905 and 409.906, excluding funds
1164for Medicaid nursing home services unless the agency is able to
1165demonstrate how the integration of the funds will improve
1166coordinated care for these services in a less costly manner; and
1167Medicare coinsurance and deductibles for persons dually eligible
1168for Medicaid and Medicare as prescribed in s. 409.908(13).
1169     (a)  Individuals who are 60 years of age or older or dually
1170eligible for Medicare and Medicaid and enrolled in the
1171developmental disabilities waiver program, the family and
1172supported-living waiver program, the project AIDS care waiver
1173program, the traumatic brain injury and spinal cord injury
1174waiver program, the consumer-directed care waiver program, and
1175the program of all-inclusive care for the elderly program, and
1176residents of institutional care facilities for the
1177developmentally disabled, must be excluded from the integrated
1179     (b)  Managed care entities who meet or exceed the agency's
1180minimum standards are eligible to operate the integrated
1181program. Entities eligible to participate include managed care
1182organizations licensed under chapter 641, including entities
1183eligible to participate in the nursing home diversion program,
1184other qualified providers as defined in s. 430.703(7), community
1185care for the elderly lead agencies, and other state-certified
1186community service networks that meet comparable standards as
1187defined by the agency, in consultation with the Department of
1188Elderly Affairs and the Office of Insurance Regulation, to be
1189financially solvent and able to take on financial risk for
1190managed care. Community service networks that are certified
1191pursuant to the comparable standards defined by the agency are
1192not required to be licensed under chapter 641. Managed care
1193entities who operate the integrated program shall be subject to
1194s. 408.7056. Eligible entities shall choose to serve enrollees
1195who are dually eligible for Medicare and Medicaid, enrollees who
1196are 60 years of age or older, or both.
1197     (c)  The agency must ensure that the capitation-rate-
1198setting methodology for the integrated program is actuarially
1199sound and reflects the intent to provide quality care in the
1200least restrictive setting. The agency must also require
1201integrated-program providers to develop a credentialing system
1202for service providers and to contract with all Gold Seal nursing
1203homes, where feasible, and exclude, where feasible, chronically
1204poor-performing facilities and providers as defined by the
1205agency. The integrated program must develop and maintain an
1206informal provider grievance system that addresses provider
1207payment and contract problems. The agency shall also establish a
1208formal grievance system to address those issues that were not
1209resolved through the informal grievance system. The integrated
1210program must provide that if the recipient resides in a
1211noncontracted residential facility licensed under chapter 400 or
1212chapter 429 at the time of enrollment in the integrated program,
1213the recipient must be permitted to continue to reside in the
1214noncontracted facility as long as the recipient desires. The
1215integrated program must also provide that, in the absence of a
1216contract between the integrated-program provider and the
1217residential facility licensed under chapter 400 or chapter 429,
1218current Medicaid rates must prevail. The integrated-program
1219provider must ensure that electronic nursing home claims that
1220contain sufficient information for processing are paid within 10
1221business days after receipt. Alternately, the integrated-program
1222provider may establish a capitated payment mechanism to
1223prospectively pay nursing homes at the beginning of each month.
1224The agency and the Department of Elderly Affairs must jointly
1225develop procedures to manage the services provided through the
1226integrated program in order to ensure quality and recipient
1228     (d)  The Office of Program Policy Analysis and Government
1229Accountability, in consultation with the Auditor General, shall
1230comprehensively evaluate the pilot project for the integrated,
1231fixed-payment delivery program for Medicaid recipients created
1232under this subsection. The evaluation shall begin as soon as
1233Medicaid recipients are enrolled in the managed care pilot
1234program plans and shall continue for 24 months thereafter. The
1235evaluation must include assessments of each managed care plan in
1236the integrated program with regard to cost savings; consumer
1237education, choice, and access to services; coordination of care;
1238and quality of care. The evaluation must describe administrative
1239or legal barriers to the implementation and operation of the
1240pilot program and include recommendations regarding statewide
1241expansion of the pilot program. The office shall submit its
1242evaluation report to the Governor, the President of the Senate,
1243and the Speaker of the House of Representatives no later than
1244December 31, 2009.
1245     (e)  The agency may seek federal waivers or Medicaid state
1246plan amendments and adopt rules as necessary to administer the
1247integrated program. The agency may implement the approved
1248federal waivers and other provisions as specified in this
1250     (f)  The implementation of the integrated, fixed-payment
1251delivery program created under this subsection is subject to an
1252appropriation in the General Appropriations Act.
1253     (5)(6)  The agency may contract with any public or private
1254entity otherwise authorized by this section on a prepaid or
1255fixed-sum basis for the provision of health care services to
1256recipients. An entity may provide prepaid services to
1257recipients, either directly or through arrangements with other
1258entities, if each entity involved in providing services:
1259     (a)  Is organized primarily for the purpose of providing
1260health care or other services of the type regularly offered to
1261Medicaid recipients;
1262     (b)  Ensures that services meet the standards set by the
1263agency for quality, appropriateness, and timeliness;
1264     (c)  Makes provisions satisfactory to the agency for
1265insolvency protection and ensures that neither enrolled Medicaid
1266recipients nor the agency will be liable for the debts of the
1268     (d)  Submits to the agency, if a private entity, a
1269financial plan that the agency finds to be fiscally sound and
1270that provides for working capital in the form of cash or
1271equivalent liquid assets excluding revenues from Medicaid
1272premium payments equal to at least the first 3 months of
1273operating expenses or $200,000, whichever is greater;
1274     (e)  Furnishes evidence satisfactory to the agency of
1275adequate liability insurance coverage or an adequate plan of
1276self-insurance to respond to claims for injuries arising out of
1277the furnishing of health care;
1278     (f)  Provides, through contract or otherwise, for periodic
1279review of its medical facilities and services, as required by
1280the agency; and
1281     (g)  Provides organizational, operational, financial, and
1282other information required by the agency.
1284This subsection expires October 1, 2014.
1285     (6)(7)  The agency may contract on a prepaid or fixed-sum
1286basis with any health insurer that:
1287     (a)  Pays for health care services provided to enrolled
1288Medicaid recipients in exchange for a premium payment paid by
1289the agency;
1290     (b)  Assumes the underwriting risk; and
1291     (c)  Is organized and licensed under applicable provisions
1292of the Florida Insurance Code and is currently in good standing
1293with the Office of Insurance Regulation.
1295This subsection expires October 1, 2014.
1296     (7)(8)(a)  The agency may contract on a prepaid or fixed-
1297sum basis with an exclusive provider organization to provide
1298health care services to Medicaid recipients provided that the
1299exclusive provider organization meets applicable managed care
1300plan requirements in this section, ss. 409.9122, 409.9123,
1301409.9128, and 627.6472, and other applicable provisions of law.
1302This subsection expires October 1, 2014.
1303     (b)  For a period of no longer than 24 months after the
1304effective date of this paragraph, when a member of an exclusive
1305provider organization that is contracted by the agency to
1306provide health care services to Medicaid recipients in rural
1307areas without a health maintenance organization obtains services
1308from a provider that participates in the Medicaid program in
1309this state, the provider shall be paid in accordance with the
1310appropriate fee schedule for services provided to eligible
1311Medicaid recipients. The agency may seek waiver authority to
1312implement this paragraph.
1313     (8)(9)  The Agency for Health Care Administration may
1314provide cost-effective purchasing of chiropractic services on a
1315fee-for-service basis to Medicaid recipients through
1316arrangements with a statewide chiropractic preferred provider
1317organization incorporated in this state as a not-for-profit
1318corporation. The agency shall ensure that the benefit limits and
1319prior authorization requirements in the current Medicaid program
1320shall apply to the services provided by the chiropractic
1321preferred provider organization. This subsection expires October
13221, 2014.
1323     (9)(10)  The agency shall not contract on a prepaid or
1324fixed-sum basis for Medicaid services with an entity which knows
1325or reasonably should know that any officer, director, agent,
1326managing employee, or owner of stock or beneficial interest in
1327excess of 5 percent common or preferred stock, or the entity
1328itself, has been found guilty of, regardless of adjudication, or
1329entered a plea of nolo contendere, or guilty, to:
1330     (a)  Fraud;
1331     (b)  Violation of federal or state antitrust statutes,
1332including those proscribing price fixing between competitors and
1333the allocation of customers among competitors;
1334     (c)  Commission of a felony involving embezzlement, theft,
1335forgery, income tax evasion, bribery, falsification or
1336destruction of records, making false statements, receiving
1337stolen property, making false claims, or obstruction of justice;
1339     (d)  Any crime in any jurisdiction which directly relates
1340to the provision of health services on a prepaid or fixed-sum
1343This subsection expires October 1, 2014.
1344     (10)(11)  The agency, after notifying the Legislature, may
1345apply for waivers of applicable federal laws and regulations as
1346necessary to implement more appropriate systems of health care
1347for Medicaid recipients and reduce the cost of the Medicaid
1348program to the state and federal governments and shall implement
1349such programs, after legislative approval, within a reasonable
1350period of time after federal approval. These programs must be
1351designed primarily to reduce the need for inpatient care,
1352custodial care and other long-term or institutional care, and
1353other high-cost services. Prior to seeking legislative approval
1354of such a waiver as authorized by this subsection, the agency
1355shall provide notice and an opportunity for public comment.
1356Notice shall be provided to all persons who have made requests
1357of the agency for advance notice and shall be published in the
1358Florida Administrative Weekly not less than 28 days prior to the
1359intended action. This subsection expires October 1, 2016.
1360     (11)(12)  The agency shall establish a postpayment
1361utilization control program designed to identify recipients who
1362may inappropriately overuse or underuse Medicaid services and
1363shall provide methods to correct such misuse. This subsection
1364expires October 1, 2014.
1365     (12)(13)  The agency shall develop and provide coordinated
1366systems of care for Medicaid recipients and may contract with
1367public or private entities to develop and administer such
1368systems of care among public and private health care providers
1369in a given geographic area. This subsection expires October 1,
1371     (13)(14)(a)  The agency shall operate or contract for the
1372operation of utilization management and incentive systems
1373designed to encourage cost-effective use of services and to
1374eliminate services that are medically unnecessary. The agency
1375shall track Medicaid provider prescription and billing patterns
1376and evaluate them against Medicaid medical necessity criteria
1377and coverage and limitation guidelines adopted by rule. Medical
1378necessity determination requires that service be consistent with
1379symptoms or confirmed diagnosis of illness or injury under
1380treatment and not in excess of the patient's needs. The agency
1381shall conduct reviews of provider exceptions to peer group norms
1382and shall, using statistical methodologies, provider profiling,
1383and analysis of billing patterns, detect and investigate
1384abnormal or unusual increases in billing or payment of claims
1385for Medicaid services and medically unnecessary provision of
1386services. Providers that demonstrate a pattern of submitting
1387claims for medically unnecessary services shall be referred to
1388the Medicaid program integrity unit for investigation. In its
1389annual report, required in s. 409.913, the agency shall report
1390on its efforts to control overutilization as described in this
1391subsection paragraph. This subsection expires October 1, 2014.
1392     (b)  The agency shall develop a procedure for determining
1393whether health care providers and service vendors can provide
1394the Medicaid program using a business case that demonstrates
1395whether a particular good or service can offset the cost of
1396providing the good or service in an alternative setting or
1397through other means and therefore should receive a higher
1398reimbursement. The business case must include, but need not be
1399limited to:
1400     1.  A detailed description of the good or service to be
1401provided, a description and analysis of the agency's current
1402performance of the service, and a rationale documenting how
1403providing the service in an alternative setting would be in the
1404best interest of the state, the agency, and its clients.
1405     2.  A cost-benefit analysis documenting the estimated
1406specific direct and indirect costs, savings, performance
1407improvements, risks, and qualitative and quantitative benefits
1408involved in or resulting from providing the service. The cost-
1409benefit analysis must include a detailed plan and timeline
1410identifying all actions that must be implemented to realize
1411expected benefits. The Secretary of Health Care Administration
1412shall verify that all costs, savings, and benefits are valid and
1414     (c)  If the agency determines that the increased
1415reimbursement is cost-effective, the agency shall recommend a
1416change in the reimbursement schedule for that particular good or
1417service. If, within 12 months after implementing any rate change
1418under this procedure, the agency determines that costs were not
1419offset by the increased reimbursement schedule, the agency may
1420revert to the former reimbursement schedule for the particular
1421good or service.
1422     (14)(15)(a)  The agency shall operate the Comprehensive
1423Assessment and Review for Long-Term Care Services (CARES)
1424nursing facility preadmission screening program to ensure that
1425Medicaid payment for nursing facility care is made only for
1426individuals whose conditions require such care and to ensure
1427that long-term care services are provided in the setting most
1428appropriate to the needs of the person and in the most
1429economical manner possible. The CARES program shall also ensure
1430that individuals participating in Medicaid home and community-
1431based waiver programs meet criteria for those programs,
1432consistent with approved federal waivers.
1433     (b)  The agency shall operate the CARES program through an
1434interagency agreement with the Department of Elderly Affairs.
1435The agency, in consultation with the Department of Elderly
1436Affairs, may contract for any function or activity of the CARES
1437program, including any function or activity required by 42
1438C.F.R. part 483.20, relating to preadmission screening and
1439resident review.
1440     (c)  Prior to making payment for nursing facility services
1441for a Medicaid recipient, the agency must verify that the
1442nursing facility preadmission screening program has determined
1443that the individual requires nursing facility care and that the
1444individual cannot be safely served in community-based programs.
1445The nursing facility preadmission screening program shall refer
1446a Medicaid recipient to a community-based program if the
1447individual could be safely served at a lower cost and the
1448recipient chooses to participate in such program. For
1449individuals whose nursing home stay is initially funded by
1450Medicare and Medicare coverage is being terminated for lack of
1451progress towards rehabilitation, CARES staff shall consult with
1452the person making the determination of progress toward
1453rehabilitation to ensure that the recipient is not being
1454inappropriately disqualified from Medicare coverage. If, in
1455their professional judgment, CARES staff believes that a
1456Medicare beneficiary is still making progress toward
1457rehabilitation, they may assist the Medicare beneficiary with an
1458appeal of the disqualification from Medicare coverage. The use
1459of CARES teams to review Medicare denials for coverage under
1460this section is authorized only if it is determined that such
1461reviews qualify for federal matching funds through Medicaid. The
1462agency shall seek or amend federal waivers as necessary to
1463implement this section.
1464     (d)  For the purpose of initiating immediate prescreening
1465and diversion assistance for individuals residing in nursing
1466homes and in order to make families aware of alternative long-
1467term care resources so that they may choose a more cost-
1468effective setting for long-term placement, CARES staff shall
1469conduct an assessment and review of a sample of individuals
1470whose nursing home stay is expected to exceed 20 days,
1471regardless of the initial funding source for the nursing home
1472placement. CARES staff shall provide counseling and referral
1473services to these individuals regarding choosing appropriate
1474long-term care alternatives. This paragraph does not apply to
1475continuing care facilities licensed under chapter 651 or to
1476retirement communities that provide a combination of nursing
1477home, independent living, and other long-term care services.
1478     (e)  By January 15 of each year, the agency shall submit a
1479report to the Legislature describing the operations of the CARES
1480program. The report must describe:
1481     1.  Rate of diversion to community alternative programs;
1482     2.  CARES program staffing needs to achieve additional
1484     3.  Reasons the program is unable to place individuals in
1485less restrictive settings when such individuals desired such
1486services and could have been served in such settings;
1487     4.  Barriers to appropriate placement, including barriers
1488due to policies or operations of other agencies or state-funded
1489programs; and
1490     5.  Statutory changes necessary to ensure that individuals
1491in need of long-term care services receive care in the least
1492restrictive environment.
1493     (f)  The Department of Elderly Affairs shall track
1494individuals over time who are assessed under the CARES program
1495and who are diverted from nursing home placement. By January 15
1496of each year, the department shall submit to the Legislature a
1497longitudinal study of the individuals who are diverted from
1498nursing home placement. The study must include:
1499     1.  The demographic characteristics of the individuals
1500assessed and diverted from nursing home placement, including,
1501but not limited to, age, race, gender, frailty, caregiver
1502status, living arrangements, and geographic location;
1503     2.  A summary of community services provided to individuals
1504for 1 year after assessment and diversion;
1505     3.  A summary of inpatient hospital admissions for
1506individuals who have been diverted; and
1507     4.  A summary of the length of time between diversion and
1508subsequent entry into a nursing home or death.
1510This subsection expires October 1, 2013.
1511     (15)(16)(a)  The agency shall identify health care
1512utilization and price patterns within the Medicaid program which
1513are not cost-effective or medically appropriate and assess the
1514effectiveness of new or alternate methods of providing and
1515monitoring service, and may implement such methods as it
1516considers appropriate. Such methods may include disease
1517management initiatives, an integrated and systematic approach
1518for managing the health care needs of recipients who are at risk
1519of or diagnosed with a specific disease by using best practices,
1520prevention strategies, clinical-practice improvement, clinical
1521interventions and protocols, outcomes research, information
1522technology, and other tools and resources to reduce overall
1523costs and improve measurable outcomes.
1524     (b)  The responsibility of the agency under this subsection
1525shall include the development of capabilities to identify actual
1526and optimal practice patterns; patient and provider educational
1527initiatives; methods for determining patient compliance with
1528prescribed treatments; fraud, waste, and abuse prevention and
1529detection programs; and beneficiary case management programs.
1530     1.  The practice pattern identification program shall
1531evaluate practitioner prescribing patterns based on national and
1532regional practice guidelines, comparing practitioners to their
1533peer groups. The agency and its Drug Utilization Review Board
1534shall consult with the Department of Health and a panel of
1535practicing health care professionals consisting of the
1536following: the Speaker of the House of Representatives and the
1537President of the Senate shall each appoint three physicians
1538licensed under chapter 458 or chapter 459; and the Governor
1539shall appoint two pharmacists licensed under chapter 465 and one
1540dentist licensed under chapter 466 who is an oral surgeon. Terms
1541of the panel members shall expire at the discretion of the
1542appointing official. The advisory panel shall be responsible for
1543evaluating treatment guidelines and recommending ways to
1544incorporate their use in the practice pattern identification
1545program. Practitioners who are prescribing inappropriately or
1546inefficiently, as determined by the agency, may have their
1547prescribing of certain drugs subject to prior authorization or
1548may be terminated from all participation in the Medicaid
1550     2.  The agency shall also develop educational interventions
1551designed to promote the proper use of medications by providers
1552and beneficiaries.
1553     3.  The agency shall implement a pharmacy fraud, waste, and
1554abuse initiative that may include a surety bond or letter of
1555credit requirement for participating pharmacies, enhanced
1556provider auditing practices, the use of additional fraud and
1557abuse software, recipient management programs for beneficiaries
1558inappropriately using their benefits, and other steps that will
1559eliminate provider and recipient fraud, waste, and abuse. The
1560initiative shall address enforcement efforts to reduce the
1561number and use of counterfeit prescriptions.
1562     4.  By September 30, 2002, the agency shall contract with
1563an entity in the state to implement a wireless handheld clinical
1564pharmacology drug information database for practitioners. The
1565initiative shall be designed to enhance the agency's efforts to
1566reduce fraud, abuse, and errors in the prescription drug benefit
1567program and to otherwise further the intent of this paragraph.
1568     5.  By April 1, 2006, the agency shall contract with an
1569entity to design a database of clinical utilization information
1570or electronic medical records for Medicaid providers. This
1571system must be web-based and allow providers to review on a
1572real-time basis the utilization of Medicaid services, including,
1573but not limited to, physician office visits, inpatient and
1574outpatient hospitalizations, laboratory and pathology services,
1575radiological and other imaging services, dental care, and
1576patterns of dispensing prescription drugs in order to coordinate
1577care and identify potential fraud and abuse.
1578     6.  The agency may apply for any federal waivers needed to
1579administer this paragraph.
1581This subsection expires October 1, 2014.
1582     (16)(17)  An entity contracting on a prepaid or fixed-sum
1583basis shall meet the surplus requirements of s. 641.225. If an
1584entity's surplus falls below an amount equal to the surplus
1585requirements of s. 641.225, the agency shall prohibit the entity
1586from engaging in marketing and preenrollment activities, shall
1587cease to process new enrollments, and may not renew the entity's
1588contract until the required balance is achieved. The
1589requirements of this subsection do not apply:
1590     (a)  Where a public entity agrees to fund any deficit
1591incurred by the contracting entity; or
1592     (b)  Where the entity's performance and obligations are
1593guaranteed in writing by a guaranteeing organization which:
1594     1.  Has been in operation for at least 5 years and has
1595assets in excess of $50 million; or
1596     2.  Submits a written guarantee acceptable to the agency
1597which is irrevocable during the term of the contracting entity's
1598contract with the agency and, upon termination of the contract,
1599until the agency receives proof of satisfaction of all
1600outstanding obligations incurred under the contract.
1602This subsection expires October 1, 2014.
1603     (17)(18)(a)  The agency may require an entity contracting
1604on a prepaid or fixed-sum basis to establish a restricted
1605insolvency protection account with a federally guaranteed
1606financial institution licensed to do business in this state. The
1607entity shall deposit into that account 5 percent of the
1608capitation payments made by the agency each month until a
1609maximum total of 2 percent of the total current contract amount
1610is reached. The restricted insolvency protection account may be
1611drawn upon with the authorized signatures of two persons
1612designated by the entity and two representatives of the agency.
1613If the agency finds that the entity is insolvent, the agency may
1614draw upon the account solely with the two authorized signatures
1615of representatives of the agency, and the funds may be disbursed
1616to meet financial obligations incurred by the entity under the
1617prepaid contract. If the contract is terminated, expired, or not
1618continued, the account balance must be released by the agency to
1619the entity upon receipt of proof of satisfaction of all
1620outstanding obligations incurred under this contract.
1621     (b)  The agency may waive the insolvency protection account
1622requirement in writing when evidence is on file with the agency
1623of adequate insolvency insurance and reinsurance that will
1624protect enrollees if the entity becomes unable to meet its
1627This subsection expires October 1, 2014.
1628     (18)(19)  An entity that contracts with the agency on a
1629prepaid or fixed-sum basis for the provision of Medicaid
1630services shall reimburse any hospital or physician that is
1631outside the entity's authorized geographic service area as
1632specified in its contract with the agency, and that provides
1633services authorized by the entity to its members, at a rate
1634negotiated with the hospital or physician for the provision of
1635services or according to the lesser of the following:
1636     (a)  The usual and customary charges made to the general
1637public by the hospital or physician; or
1638     (b)  The Florida Medicaid reimbursement rate established
1639for the hospital or physician.
1641This subsection expires October 1, 2014.
1642     (19)(20)  When a merger or acquisition of a Medicaid
1643prepaid contractor has been approved by the Office of Insurance
1644Regulation pursuant to s. 628.4615, the agency shall approve the
1645assignment or transfer of the appropriate Medicaid prepaid
1646contract upon request of the surviving entity of the merger or
1647acquisition if the contractor and the other entity have been in
1648good standing with the agency for the most recent 12-month
1649period, unless the agency determines that the assignment or
1650transfer would be detrimental to the Medicaid recipients or the
1651Medicaid program. To be in good standing, an entity must not
1652have failed accreditation or committed any material violation of
1653the requirements of s. 641.52 and must meet the Medicaid
1654contract requirements. For purposes of this section, a merger or
1655acquisition means a change in controlling interest of an entity,
1656including an asset or stock purchase. This subsection expires
1657October 1, 2014.
1658     (20)(21)  Any entity contracting with the agency pursuant
1659to this section to provide health care services to Medicaid
1660recipients is prohibited from engaging in any of the following
1661practices or activities:
1662     (a)  Practices that are discriminatory, including, but not
1663limited to, attempts to discourage participation on the basis of
1664actual or perceived health status.
1665     (b)  Activities that could mislead or confuse recipients,
1666or misrepresent the organization, its marketing representatives,
1667or the agency. Violations of this paragraph include, but are not
1668limited to:
1669     1.  False or misleading claims that marketing
1670representatives are employees or representatives of the state or
1671county, or of anyone other than the entity or the organization
1672by whom they are reimbursed.
1673     2.  False or misleading claims that the entity is
1674recommended or endorsed by any state or county agency, or by any
1675other organization which has not certified its endorsement in
1676writing to the entity.
1677     3.  False or misleading claims that the state or county
1678recommends that a Medicaid recipient enroll with an entity.
1679     4.  Claims that a Medicaid recipient will lose benefits
1680under the Medicaid program, or any other health or welfare
1681benefits to which the recipient is legally entitled, if the
1682recipient does not enroll with the entity.
1683     (c)  Granting or offering of any monetary or other valuable
1684consideration for enrollment, except as authorized by subsection
1685(23) (24).
1686     (d)  Door-to-door solicitation of recipients who have not
1687contacted the entity or who have not invited the entity to make
1688a presentation.
1689     (e)  Solicitation of Medicaid recipients by marketing
1690representatives stationed in state offices unless approved and
1691supervised by the agency or its agent and approved by the
1692affected state agency when solicitation occurs in an office of
1693the state agency. The agency shall ensure that marketing
1694representatives stationed in state offices shall market their
1695managed care plans to Medicaid recipients only in designated
1696areas and in such a way as to not interfere with the recipients'
1697activities in the state office.
1698     (f)  Enrollment of Medicaid recipients.
1700This subsection expires October 1, 2014.
1701     (21)(22)  The agency may impose a fine for a violation of
1702this section or the contract with the agency by a person or
1703entity that is under contract with the agency. With respect to
1704any nonwillful violation, such fine shall not exceed $2,500 per
1705violation. In no event shall such fine exceed an aggregate
1706amount of $10,000 for all nonwillful violations arising out of
1707the same action. With respect to any knowing and willful
1708violation of this section or the contract with the agency, the
1709agency may impose a fine upon the entity in an amount not to
1710exceed $20,000 for each such violation. In no event shall such
1711fine exceed an aggregate amount of $100,000 for all knowing and
1712willful violations arising out of the same action. This
1713subsection expires October 1, 2014.
1714     (22)(23)  A health maintenance organization or a person or
1715entity exempt from chapter 641 that is under contract with the
1716agency for the provision of health care services to Medicaid
1717recipients may not use or distribute marketing materials used to
1718solicit Medicaid recipients, unless such materials have been
1719approved by the agency. The provisions of this subsection do not
1720apply to general advertising and marketing materials used by a
1721health maintenance organization to solicit both non-Medicaid
1722subscribers and Medicaid recipients. This subsection expires
1723October 1, 2014.
1724     (23)(24)  Upon approval by the agency, health maintenance
1725organizations and persons or entities exempt from chapter 641
1726that are under contract with the agency for the provision of
1727health care services to Medicaid recipients may be permitted
1728within the capitation rate to provide additional health benefits
1729that the agency has found are of high quality, are practicably
1730available, provide reasonable value to the recipient, and are
1731provided at no additional cost to the state. This subsection
1732expires October 1, 2014.
1733     (24)(25)  The agency shall utilize the statewide health
1734maintenance organization complaint hotline for the purpose of
1735investigating and resolving Medicaid and prepaid health plan
1736complaints, maintaining a record of complaints and confirmed
1737problems, and receiving disenrollment requests made by
1738recipients. This subsection expires October 1, 2014.
1739     (25)(26)  The agency shall require the publication of the
1740health maintenance organization's and the prepaid health plan's
1741consumer services telephone numbers and the "800" telephone
1742number of the statewide health maintenance organization
1743complaint hotline on each Medicaid identification card issued by
1744a health maintenance organization or prepaid health plan
1745contracting with the agency to serve Medicaid recipients and on
1746each subscriber handbook issued to a Medicaid recipient. This
1747subsection expires October 1, 2014.
1748     (26)(27)  The agency shall establish a health care quality
1749improvement system for those entities contracting with the
1750agency pursuant to this section, incorporating all the standards
1751and guidelines developed by the Medicaid Bureau of the Health
1752Care Financing Administration as a part of the quality assurance
1753reform initiative. The system shall include, but need not be
1754limited to, the following:
1755     (a)  Guidelines for internal quality assurance programs,
1756including standards for:
1757     1.  Written quality assurance program descriptions.
1758     2.  Responsibilities of the governing body for monitoring,
1759evaluating, and making improvements to care.
1760     3.  An active quality assurance committee.
1761     4.  Quality assurance program supervision.
1762     5.  Requiring the program to have adequate resources to
1763effectively carry out its specified activities.
1764     6.  Provider participation in the quality assurance
1766     7.  Delegation of quality assurance program activities.
1767     8.  Credentialing and recredentialing.
1768     9.  Enrollee rights and responsibilities.
1769     10.  Availability and accessibility to services and care.
1770     11.  Ambulatory care facilities.
1771     12.  Accessibility and availability of medical records, as
1772well as proper recordkeeping and process for record review.
1773     13.  Utilization review.
1774     14.  A continuity of care system.
1775     15.  Quality assurance program documentation.
1776     16.  Coordination of quality assurance activity with other
1777management activity.
1778     17.  Delivering care to pregnant women and infants; to
1779elderly and disabled recipients, especially those who are at
1780risk of institutional placement; to persons with developmental
1781disabilities; and to adults who have chronic, high-cost medical
1783     (b)  Guidelines which require the entities to conduct
1784quality-of-care studies which:
1785     1.  Target specific conditions and specific health service
1786delivery issues for focused monitoring and evaluation.
1787     2.  Use clinical care standards or practice guidelines to
1788objectively evaluate the care the entity delivers or fails to
1789deliver for the targeted clinical conditions and health services
1790delivery issues.
1791     3.  Use quality indicators derived from the clinical care
1792standards or practice guidelines to screen and monitor care and
1793services delivered.
1794     (c)  Guidelines for external quality review of each
1795contractor which require: focused studies of patterns of care;
1796individual care review in specific situations; and followup
1797activities on previous pattern-of-care study findings and
1798individual-care-review findings. In designing the external
1799quality review function and determining how it is to operate as
1800part of the state's overall quality improvement system, the
1801agency shall construct its external quality review organization
1802and entity contracts to address each of the following:
1803     1.  Delineating the role of the external quality review
1805     2.  Length of the external quality review organization
1806contract with the state.
1807     3.  Participation of the contracting entities in designing
1808external quality review organization review activities.
1809     4.  Potential variation in the type of clinical conditions
1810and health services delivery issues to be studied at each plan.
1811     5.  Determining the number of focused pattern-of-care
1812studies to be conducted for each plan.
1813     6.  Methods for implementing focused studies.
1814     7.  Individual care review.
1815     8.  Followup activities.
1817This subsection expires October 1, 2016.
1818     (27)(28)  In order to ensure that children receive health
1819care services for which an entity has already been compensated,
1820an entity contracting with the agency pursuant to this section
1821shall achieve an annual Early and Periodic Screening, Diagnosis,
1822and Treatment (EPSDT) Service screening rate of at least 60
1823percent for those recipients continuously enrolled for at least
18248 months. The agency shall develop a method by which the EPSDT
1825screening rate shall be calculated. For any entity which does
1826not achieve the annual 60 percent rate, the entity must submit a
1827corrective action plan for the agency's approval. If the entity
1828does not meet the standard established in the corrective action
1829plan during the specified timeframe, the agency is authorized to
1830impose appropriate contract sanctions. At least annually, the
1831agency shall publicly release the EPSDT Services screening rates
1832of each entity it has contracted with on a prepaid basis to
1833serve Medicaid recipients. This subsection expires October 1,
1835     (28)(29)  The agency shall perform enrollments and
1836disenrollments for Medicaid recipients who are eligible for
1837MediPass or managed care plans. Notwithstanding the prohibition
1838contained in paragraph (20)(21)(f), managed care plans may
1839perform preenrollments of Medicaid recipients under the
1840supervision of the agency or its agents. For the purposes of
1841this section, the term "preenrollment" means the provision of
1842marketing and educational materials to a Medicaid recipient and
1843assistance in completing the application forms, but does not
1844include actual enrollment into a managed care plan. An
1845application for enrollment may not be deemed complete until the
1846agency or its agent verifies that the recipient made an
1847informed, voluntary choice. The agency, in cooperation with the
1848Department of Children and Family Services, may test new
1849marketing initiatives to inform Medicaid recipients about their
1850managed care options at selected sites. The agency may contract
1851with a third party to perform managed care plan and MediPass
1852enrollment and disenrollment services for Medicaid recipients
1853and may adopt rules to administer such services. The agency may
1854adjust the capitation rate only to cover the costs of a third-
1855party enrollment and disenrollment contract, and for agency
1856supervision and management of the managed care plan enrollment
1857and disenrollment contract. This subsection expires October 1,
1859     (29)(30)  Any lists of providers made available to Medicaid
1860recipients, MediPass enrollees, or managed care plan enrollees
1861shall be arranged alphabetically showing the provider's name and
1862specialty and, separately, by specialty in alphabetical order.
1863This subsection expires October 1, 2014.
1864     (30)(31)  The agency shall establish an enhanced managed
1865care quality assurance oversight function, to include at least
1866the following components:
1867     (a)  At least quarterly analysis and followup, including
1868sanctions as appropriate, of managed care participant
1869utilization of services.
1870     (b)  At least quarterly analysis and followup, including
1871sanctions as appropriate, of quality findings of the Medicaid
1872peer review organization and other external quality assurance
1874     (c)  At least quarterly analysis and followup, including
1875sanctions as appropriate, of the fiscal viability of managed
1876care plans.
1877     (d)  At least quarterly analysis and followup, including
1878sanctions as appropriate, of managed care participant
1879satisfaction and disenrollment surveys.
1880     (e)  The agency shall conduct regular and ongoing Medicaid
1881recipient satisfaction surveys.
1883The analyses and followup activities conducted by the agency
1884under its enhanced managed care quality assurance oversight
1885function shall not duplicate the activities of accreditation
1886reviewers for entities regulated under part III of chapter 641,
1887but may include a review of the finding of such reviewers. This
1888subsection expires October 1, 2014.
1889     (31)(32)  Each managed care plan that is under contract
1890with the agency to provide health care services to Medicaid
1891recipients shall annually conduct a background check with the
1892Department of Law Enforcement of all persons with ownership
1893interest of 5 percent or more or executive management
1894responsibility for the managed care plan and shall submit to the
1895agency information concerning any such person who has been found
1896guilty of, regardless of adjudication, or has entered a plea of
1897nolo contendere or guilty to, any of the offenses listed in s.
1898435.04. This subsection expires October 1, 2014.
1899     (32)(33)  The agency shall, by rule, develop a process
1900whereby a Medicaid managed care plan enrollee who wishes to
1901enter hospice care may be disenrolled from the managed care plan
1902within 24 hours after contacting the agency regarding such
1903request. The agency rule shall include a methodology for the
1904agency to recoup managed care plan payments on a pro rata basis
1905if payment has been made for the enrollment month when
1906disenrollment occurs. This subsection expires October 1, 2014.
1907     (33)(34)  The agency and entities that contract with the
1908agency to provide health care services to Medicaid recipients
1909under this section or ss. 409.91211 and 409.9122 must comply
1910with the provisions of s. 641.513 in providing emergency
1911services and care to Medicaid recipients and MediPass
1912recipients. Where feasible, safe, and cost-effective, the agency
1913shall encourage hospitals, emergency medical services providers,
1914and other public and private health care providers to work
1915together in their local communities to enter into agreements or
1916arrangements to ensure access to alternatives to emergency
1917services and care for those Medicaid recipients who need
1918nonemergent care. The agency shall coordinate with hospitals,
1919emergency medical services providers, private health plans,
1920capitated managed care networks as established in s. 409.91211,
1921and other public and private health care providers to implement
1922the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1923and 641.31097 to develop and implement emergency department
1924diversion programs for Medicaid recipients. This subsection
1925expires October 1, 2014.
1926     (34)(35)  All entities providing health care services to
1927Medicaid recipients shall make available, and encourage all
1928pregnant women and mothers with infants to receive, and provide
1929documentation in the medical records to reflect, the following:
1930     (a)  Healthy Start prenatal or infant screening.
1931     (b)  Healthy Start care coordination, when screening or
1932other factors indicate need.
1933     (c)  Healthy Start enhanced services in accordance with the
1934prenatal or infant screening results.
1935     (d)  Immunizations in accordance with recommendations of
1936the Advisory Committee on Immunization Practices of the United
1937States Public Health Service and the American Academy of
1938Pediatrics, as appropriate.
1939     (e)  Counseling and services for family planning to all
1940women and their partners.
1941     (f)  A scheduled postpartum visit for the purpose of
1942voluntary family planning, to include discussion of all methods
1943of contraception, as appropriate.
1944     (g)  Referral to the Special Supplemental Nutrition Program
1945for Women, Infants, and Children (WIC).
1947This subsection expires October 1, 2014.
1948     (35)(36)  Any entity that provides Medicaid prepaid health
1949plan services shall ensure the appropriate coordination of
1950health care services with an assisted living facility in cases
1951where a Medicaid recipient is both a member of the entity's
1952prepaid health plan and a resident of the assisted living
1953facility. If the entity is at risk for Medicaid targeted case
1954management and behavioral health services, the entity shall
1955inform the assisted living facility of the procedures to follow
1956should an emergent condition arise. This subsection expires
1957October 1, 2014.
1958     (37)  The agency may seek and implement federal waivers
1959necessary to provide for cost-effective purchasing of home
1960health services, private duty nursing services, transportation,
1961independent laboratory services, and durable medical equipment
1962and supplies through competitive bidding pursuant to s. 287.057.
1963The agency may request appropriate waivers from the federal
1964Health Care Financing Administration in order to competitively
1965bid such services. The agency may exclude providers not selected
1966through the bidding process from the Medicaid provider network.
1967     (36)(38)  The agency shall enter into agreements with not-
1968for-profit organizations based in this state for the purpose of
1969providing vision screening. This subsection expires October 1,
1971     (37)(39)(a)  The agency shall implement a Medicaid
1972prescribed-drug spending-control program that includes the
1973following components:
1974     1.  A Medicaid preferred drug list, which shall be a
1975listing of cost-effective therapeutic options recommended by the
1976Medicaid Pharmacy and Therapeutics Committee established
1977pursuant to s. 409.91195 and adopted by the agency for each
1978therapeutic class on the preferred drug list. At the discretion
1979of the committee, and when feasible, the preferred drug list
1980should include at least two products in a therapeutic class. The
1981agency may post the preferred drug list and updates to the
1982preferred drug list on an Internet website without following the
1983rulemaking procedures of chapter 120. Antiretroviral agents are
1984excluded from the preferred drug list. The agency shall also
1985limit the amount of a prescribed drug dispensed to no more than
1986a 34-day supply unless the drug products' smallest marketed
1987package is greater than a 34-day supply, or the drug is
1988determined by the agency to be a maintenance drug in which case
1989a 100-day maximum supply may be authorized. The agency is
1990authorized to seek any federal waivers necessary to implement
1991these cost-control programs and to continue participation in the
1992federal Medicaid rebate program, or alternatively to negotiate
1993state-only manufacturer rebates. The agency may adopt rules to
1994implement this subparagraph. The agency shall continue to
1995provide unlimited contraceptive drugs and items. The agency must
1996establish procedures to ensure that:
1997     a.  There is a response to a request for prior consultation
1998by telephone or other telecommunication device within 24 hours
1999after receipt of a request for prior consultation; and
2000     b.  A 72-hour supply of the drug prescribed is provided in
2001an emergency or when the agency does not provide a response
2002within 24 hours as required by sub-subparagraph a.
2003     2.  Reimbursement to pharmacies for Medicaid prescribed
2004drugs shall be set at the lesser of: the average wholesale price
2005(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2006plus 4.75 percent, the federal upper limit (FUL), the state
2007maximum allowable cost (SMAC), or the usual and customary (UAC)
2008charge billed by the provider.
2009     3.  The agency shall develop and implement a process for
2010managing the drug therapies of Medicaid recipients who are using
2011significant numbers of prescribed drugs each month. The
2012management process may include, but is not limited to,
2013comprehensive, physician-directed medical-record reviews, claims
2014analyses, and case evaluations to determine the medical
2015necessity and appropriateness of a patient's treatment plan and
2016drug therapies. The agency may contract with a private
2017organization to provide drug-program-management services. The
2018Medicaid drug benefit management program shall include
2019initiatives to manage drug therapies for HIV/AIDS patients,
2020patients using 20 or more unique prescriptions in a 180-day
2021period, and the top 1,000 patients in annual spending. The
2022agency shall enroll any Medicaid recipient in the drug benefit
2023management program if he or she meets the specifications of this
2024provision and is not enrolled in a Medicaid health maintenance
2026     4.  The agency may limit the size of its pharmacy network
2027based on need, competitive bidding, price negotiations,
2028credentialing, or similar criteria. The agency shall give
2029special consideration to rural areas in determining the size and
2030location of pharmacies included in the Medicaid pharmacy
2031network. A pharmacy credentialing process may include criteria
2032such as a pharmacy's full-service status, location, size,
2033patient educational programs, patient consultation, disease
2034management services, and other characteristics. The agency may
2035impose a moratorium on Medicaid pharmacy enrollment when it is
2036determined that it has a sufficient number of Medicaid-
2037participating providers. The agency must allow dispensing
2038practitioners to participate as a part of the Medicaid pharmacy
2039network regardless of the practitioner's proximity to any other
2040entity that is dispensing prescription drugs under the Medicaid
2041program. A dispensing practitioner must meet all credentialing
2042requirements applicable to his or her practice, as determined by
2043the agency.
2044     5.  The agency shall develop and implement a program that
2045requires Medicaid practitioners who prescribe drugs to use a
2046counterfeit-proof prescription pad for Medicaid prescriptions.
2047The agency shall require the use of standardized counterfeit-
2048proof prescription pads by Medicaid-participating prescribers or
2049prescribers who write prescriptions for Medicaid recipients. The
2050agency may implement the program in targeted geographic areas or
2052     6.  The agency may enter into arrangements that require
2053manufacturers of generic drugs prescribed to Medicaid recipients
2054to provide rebates of at least 15.1 percent of the average
2055manufacturer price for the manufacturer's generic products.
2056These arrangements shall require that if a generic-drug
2057manufacturer pays federal rebates for Medicaid-reimbursed drugs
2058at a level below 15.1 percent, the manufacturer must provide a
2059supplemental rebate to the state in an amount necessary to
2060achieve a 15.1-percent rebate level.
2061     7.  The agency may establish a preferred drug list as
2062described in this subsection, and, pursuant to the establishment
2063of such preferred drug list, it is authorized to negotiate
2064supplemental rebates from manufacturers that are in addition to
2065those required by Title XIX of the Social Security Act and at no
2066less than 14 percent of the average manufacturer price as
2067defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2068the federal or supplemental rebate, or both, equals or exceeds
206929 percent. There is no upper limit on the supplemental rebates
2070the agency may negotiate. The agency may determine that specific
2071products, brand-name or generic, are competitive at lower rebate
2072percentages. Agreement to pay the minimum supplemental rebate
2073percentage will guarantee a manufacturer that the Medicaid
2074Pharmaceutical and Therapeutics Committee will consider a
2075product for inclusion on the preferred drug list. However, a
2076pharmaceutical manufacturer is not guaranteed placement on the
2077preferred drug list by simply paying the minimum supplemental
2078rebate. Agency decisions will be made on the clinical efficacy
2079of a drug and recommendations of the Medicaid Pharmaceutical and
2080Therapeutics Committee, as well as the price of competing
2081products minus federal and state rebates. The agency is
2082authorized to contract with an outside agency or contractor to
2083conduct negotiations for supplemental rebates. For the purposes
2084of this section, the term "supplemental rebates" means cash
2085rebates. Effective July 1, 2004, value-added programs as a
2086substitution for supplemental rebates are prohibited. The agency
2087is authorized to seek any federal waivers to implement this
2089     8.  The Agency for Health Care Administration shall expand
2090home delivery of pharmacy products. To assist Medicaid patients
2091in securing their prescriptions and reduce program costs, the
2092agency shall expand its current mail-order-pharmacy diabetes-
2093supply program to include all generic and brand-name drugs used
2094by Medicaid patients with diabetes. Medicaid recipients in the
2095current program may obtain nondiabetes drugs on a voluntary
2096basis. This initiative is limited to the geographic area covered
2097by the current contract. The agency may seek and implement any
2098federal waivers necessary to implement this subparagraph.
2099     9.  The agency shall limit to one dose per month any drug
2100prescribed to treat erectile dysfunction.
2101     10.a.  The agency may implement a Medicaid behavioral drug
2102management system. The agency may contract with a vendor that
2103has experience in operating behavioral drug management systems
2104to implement this program. The agency is authorized to seek
2105federal waivers to implement this program.
2106     b.  The agency, in conjunction with the Department of
2107Children and Family Services, may implement the Medicaid
2108behavioral drug management system that is designed to improve
2109the quality of care and behavioral health prescribing practices
2110based on best practice guidelines, improve patient adherence to
2111medication plans, reduce clinical risk, and lower prescribed
2112drug costs and the rate of inappropriate spending on Medicaid
2113behavioral drugs. The program may include the following
2115     (I)  Provide for the development and adoption of best
2116practice guidelines for behavioral health-related drugs such as
2117antipsychotics, antidepressants, and medications for treating
2118bipolar disorders and other behavioral conditions; translate
2119them into practice; review behavioral health prescribers and
2120compare their prescribing patterns to a number of indicators
2121that are based on national standards; and determine deviations
2122from best practice guidelines.
2123     (II)  Implement processes for providing feedback to and
2124educating prescribers using best practice educational materials
2125and peer-to-peer consultation.
2126     (III)  Assess Medicaid beneficiaries who are outliers in
2127their use of behavioral health drugs with regard to the numbers
2128and types of drugs taken, drug dosages, combination drug
2129therapies, and other indicators of improper use of behavioral
2130health drugs.
2131     (IV)  Alert prescribers to patients who fail to refill
2132prescriptions in a timely fashion, are prescribed multiple same-
2133class behavioral health drugs, and may have other potential
2134medication problems.
2135     (V)  Track spending trends for behavioral health drugs and
2136deviation from best practice guidelines.
2137     (VI)  Use educational and technological approaches to
2138promote best practices, educate consumers, and train prescribers
2139in the use of practice guidelines.
2140     (VII)  Disseminate electronic and published materials.
2141     (VIII)  Hold statewide and regional conferences.
2142     (IX)  Implement a disease management program with a model
2143quality-based medication component for severely mentally ill
2144individuals and emotionally disturbed children who are high
2145users of care.
2146     11.a.  The agency shall implement a Medicaid prescription
2147drug management system. The agency may contract with a vendor
2148that has experience in operating prescription drug management
2149systems in order to implement this system. Any management system
2150that is implemented in accordance with this subparagraph must
2151rely on cooperation between physicians and pharmacists to
2152determine appropriate practice patterns and clinical guidelines
2153to improve the prescribing, dispensing, and use of drugs in the
2154Medicaid program. The agency may seek federal waivers to
2155implement this program.
2156     b.  The drug management system must be designed to improve
2157the quality of care and prescribing practices based on best
2158practice guidelines, improve patient adherence to medication
2159plans, reduce clinical risk, and lower prescribed drug costs and
2160the rate of inappropriate spending on Medicaid prescription
2161drugs. The program must:
2162     (I)  Provide for the development and adoption of best
2163practice guidelines for the prescribing and use of drugs in the
2164Medicaid program, including translating best practice guidelines
2165into practice; reviewing prescriber patterns and comparing them
2166to indicators that are based on national standards and practice
2167patterns of clinical peers in their community, statewide, and
2168nationally; and determine deviations from best practice
2170     (II)  Implement processes for providing feedback to and
2171educating prescribers using best practice educational materials
2172and peer-to-peer consultation.
2173     (III)  Assess Medicaid recipients who are outliers in their
2174use of a single or multiple prescription drugs with regard to
2175the numbers and types of drugs taken, drug dosages, combination
2176drug therapies, and other indicators of improper use of
2177prescription drugs.
2178     (IV)  Alert prescribers to patients who fail to refill
2179prescriptions in a timely fashion, are prescribed multiple drugs
2180that may be redundant or contraindicated, or may have other
2181potential medication problems.
2182     (V)  Track spending trends for prescription drugs and
2183deviation from best practice guidelines.
2184     (VI)  Use educational and technological approaches to
2185promote best practices, educate consumers, and train prescribers
2186in the use of practice guidelines.
2187     (VII)  Disseminate electronic and published materials.
2188     (VIII)  Hold statewide and regional conferences.
2189     (IX)  Implement disease management programs in cooperation
2190with physicians and pharmacists, along with a model quality-
2191based medication component for individuals having chronic
2192medical conditions.
2193     12.  The agency is authorized to contract for drug rebate
2194administration, including, but not limited to, calculating
2195rebate amounts, invoicing manufacturers, negotiating disputes
2196with manufacturers, and maintaining a database of rebate
2198     13.  The agency may specify the preferred daily dosing form
2199or strength for the purpose of promoting best practices with
2200regard to the prescribing of certain drugs as specified in the
2201General Appropriations Act and ensuring cost-effective
2202prescribing practices.
2203     14.  The agency may require prior authorization for
2204Medicaid-covered prescribed drugs. The agency may, but is not
2205required to, prior-authorize the use of a product:
2206     a.  For an indication not approved in labeling;
2207     b.  To comply with certain clinical guidelines; or
2208     c.  If the product has the potential for overuse, misuse,
2209or abuse.
2211The agency may require the prescribing professional to provide
2212information about the rationale and supporting medical evidence
2213for the use of a drug. The agency may post prior authorization
2214criteria and protocol and updates to the list of drugs that are
2215subject to prior authorization on an Internet website without
2216amending its rule or engaging in additional rulemaking.
2217     15.  The agency, in conjunction with the Pharmaceutical and
2218Therapeutics Committee, may require age-related prior
2219authorizations for certain prescribed drugs. The agency may
2220preauthorize the use of a drug for a recipient who may not meet
2221the age requirement or may exceed the length of therapy for use
2222of this product as recommended by the manufacturer and approved
2223by the Food and Drug Administration. Prior authorization may
2224require the prescribing professional to provide information
2225about the rationale and supporting medical evidence for the use
2226of a drug.
2227     16.  The agency shall implement a step-therapy prior
2228authorization approval process for medications excluded from the
2229preferred drug list. Medications listed on the preferred drug
2230list must be used within the previous 12 months prior to the
2231alternative medications that are not listed. The step-therapy
2232prior authorization may require the prescriber to use the
2233medications of a similar drug class or for a similar medical
2234indication unless contraindicated in the Food and Drug
2235Administration labeling. The trial period between the specified
2236steps may vary according to the medical indication. The step-
2237therapy approval process shall be developed in accordance with
2238the committee as stated in s. 409.91195(7) and (8). A drug
2239product may be approved without meeting the step-therapy prior
2240authorization criteria if the prescribing physician provides the
2241agency with additional written medical or clinical documentation
2242that the product is medically necessary because:
2243     a.  There is not a drug on the preferred drug list to treat
2244the disease or medical condition which is an acceptable clinical
2246     b.  The alternatives have been ineffective in the treatment
2247of the beneficiary's disease; or
2248     c.  Based on historic evidence and known characteristics of
2249the patient and the drug, the drug is likely to be ineffective,
2250or the number of doses have been ineffective.
2252The agency shall work with the physician to determine the best
2253alternative for the patient. The agency may adopt rules waiving
2254the requirements for written clinical documentation for specific
2255drugs in limited clinical situations.
2256     17.  The agency shall implement a return and reuse program
2257for drugs dispensed by pharmacies to institutional recipients,
2258which includes payment of a $5 restocking fee for the
2259implementation and operation of the program. The return and
2260reuse program shall be implemented electronically and in a
2261manner that promotes efficiency. The program must permit a
2262pharmacy to exclude drugs from the program if it is not
2263practical or cost-effective for the drug to be included and must
2264provide for the return to inventory of drugs that cannot be
2265credited or returned in a cost-effective manner. The agency
2266shall determine if the program has reduced the amount of
2267Medicaid prescription drugs which are destroyed on an annual
2268basis and if there are additional ways to ensure more
2269prescription drugs are not destroyed which could safely be
2270reused. The agency's conclusion and recommendations shall be
2271reported to the Legislature by December 1, 2005.
2272     (b)  The agency shall implement this subsection to the
2273extent that funds are appropriated to administer the Medicaid
2274prescribed-drug spending-control program. The agency may
2275contract all or any part of this program to private
2277     (c)  The agency shall submit quarterly reports to the
2278Governor, the President of the Senate, and the Speaker of the
2279House of Representatives which must include, but need not be
2280limited to, the progress made in implementing this subsection
2281and its effect on Medicaid prescribed-drug expenditures.
2282     (38)(40)  Notwithstanding the provisions of chapter 287,
2283the agency may, at its discretion, renew a contract or contracts
2284for fiscal intermediary services one or more times for such
2285periods as the agency may decide; however, all such renewals may
2286not combine to exceed a total period longer than the term of the
2287original contract.
2288     (39)(41)  The agency shall provide for the development of a
2289demonstration project by establishment in Miami-Dade County of a
2290long-term-care facility licensed pursuant to chapter 395 to
2291improve access to health care for a predominantly minority,
2292medically underserved, and medically complex population and to
2293evaluate alternatives to nursing home care and general acute
2294care for such population. Such project is to be located in a
2295health care condominium and colocated with licensed facilities
2296providing a continuum of care. The establishment of this project
2297is not subject to the provisions of s. 408.036 or s. 408.039.
2298This subsection expires October 1, 2013.
2299     (42)  The agency shall develop and implement a utilization
2300management program for Medicaid-eligible recipients for the
2301management of occupational, physical, respiratory, and speech
2302therapies. The agency shall establish a utilization program that
2303may require prior authorization in order to ensure medically
2304necessary and cost-effective treatments. The program shall be
2305operated in accordance with a federally approved waiver program
2306or state plan amendment. The agency may seek a federal waiver or
2307state plan amendment to implement this program. The agency may
2308also competitively procure these services from an outside vendor
2309on a regional or statewide basis.
2310     (40)(43)  The agency shall may contract on a prepaid or
2311fixed-sum basis with appropriately licensed prepaid dental
2312health plans to provide dental services. This subsection expires
2313October 1, 2014.
2314     (41)(44)  The Agency for Health Care Administration shall
2315ensure that any Medicaid managed care plan as defined in s.
2316409.9122(2)(f), whether paid on a capitated basis or a shared
2317savings basis, is cost-effective. For purposes of this
2318subsection, the term "cost-effective" means that a network's
2319per-member, per-month costs to the state, including, but not
2320limited to, fee-for-service costs, administrative costs, and
2321case-management fees, if any, must be no greater than the
2322state's costs associated with contracts for Medicaid services
2323established under subsection (3), which may be adjusted for
2324health status. The agency shall conduct actuarially sound
2325adjustments for health status in order to ensure such cost-
2326effectiveness and shall annually publish the results on its
2327Internet website. Contracts established pursuant to this
2328subsection which are not cost-effective may not be renewed. This
2329subsection expires October 1, 2014.
2330     (42)(45)  Subject to the availability of funds, the agency
2331shall mandate a recipient's participation in a provider lock-in
2332program, when appropriate, if a recipient is found by the agency
2333to have used Medicaid goods or services at a frequency or amount
2334not medically necessary, limiting the receipt of goods or
2335services to medically necessary providers after the 21-day
2336appeal process has ended, for a period of not less than 1 year.
2337The lock-in programs shall include, but are not limited to,
2338pharmacies, medical doctors, and infusion clinics. The
2339limitation does not apply to emergency services and care
2340provided to the recipient in a hospital emergency department.
2341The agency shall seek any federal waivers necessary to implement
2342this subsection. The agency shall adopt any rules necessary to
2343comply with or administer this subsection. This subsection
2344expires October 1, 2014.
2345     (43)(46)  The agency shall seek a federal waiver for
2346permission to terminate the eligibility of a Medicaid recipient
2347who has been found to have committed fraud, through judicial or
2348administrative determination, two times in a period of 5 years.
2349     (47)  The agency shall conduct a study of available
2350electronic systems for the purpose of verifying the identity and
2351eligibility of a Medicaid recipient. The agency shall recommend
2352to the Legislature a plan to implement an electronic
2353verification system for Medicaid recipients by January 31, 2005.
2354     (44)(48)(a)  A provider is not entitled to enrollment in
2355the Medicaid provider network. The agency may implement a
2356Medicaid fee-for-service provider network controls, including,
2357but not limited to, competitive procurement and provider
2358credentialing. If a credentialing process is used, the agency
2359may limit its provider network based upon the following
2360considerations: beneficiary access to care, provider
2361availability, provider quality standards and quality assurance
2362processes, cultural competency, demographic characteristics of
2363beneficiaries, practice standards, service wait times, provider
2364turnover, provider licensure and accreditation history, program
2365integrity history, peer review, Medicaid policy and billing
2366compliance records, clinical and medical record audit findings,
2367and such other areas that are considered necessary by the agency
2368to ensure the integrity of the program.
2369     (b)  The agency shall limit its network of durable medical
2370equipment and medical supply providers. For dates of service
2371after January 1, 2009, the agency shall limit payment for
2372durable medical equipment and supplies to providers that meet
2373all the requirements of this paragraph.
2374     1.  Providers must be accredited by a Centers for Medicare
2375and Medicaid Services deemed accreditation organization for
2376suppliers of durable medical equipment, prosthetics, orthotics,
2377and supplies. The provider must maintain accreditation and is
2378subject to unannounced reviews by the accrediting organization.
2379     2.  Providers must provide the services or supplies
2380directly to the Medicaid recipient or caregiver at the provider
2381location or recipient's residence or send the supplies directly
2382to the recipient's residence with receipt of mailed delivery.
2383Subcontracting or consignment of the service or supply to a
2384third party is prohibited.
2385     3.  Notwithstanding subparagraph 2., a durable medical
2386equipment provider may store nebulizers at a physician's office
2387for the purpose of having the physician's staff issue the
2388equipment if it meets all of the following conditions:
2389     a.  The physician must document the medical necessity and
2390need to prevent further deterioration of the patient's
2391respiratory status by the timely delivery of the nebulizer in
2392the physician's office.
2393     b.  The durable medical equipment provider must have
2394written documentation of the competency and training by a
2395Florida-licensed registered respiratory therapist of any durable
2396medical equipment staff who participate in the training of
2397physician office staff for the use of nebulizers, including
2398cleaning, warranty, and special needs of patients.
2399     c.  The physician's office must have documented the
2400training and competency of any staff member who initiates the
2401delivery of nebulizers to patients. The durable medical
2402equipment provider must maintain copies of all physician office
2404     d.  The physician's office must maintain inventory records
2405of stored nebulizers, including documentation of the durable
2406medical equipment provider source.
2407     e.  A physician contracted with a Medicaid durable medical
2408equipment provider may not have a financial relationship with
2409that provider or receive any financial gain from the delivery of
2410nebulizers to patients.
2411     4.  Providers must have a physical business location and a
2412functional landline business phone. The location must be within
2413the state or not more than 50 miles from the Florida state line.
2414The agency may make exceptions for providers of durable medical
2415equipment or supplies not otherwise available from other
2416enrolled providers located within the state.
2417     5.  Physical business locations must be clearly identified
2418as a business that furnishes durable medical equipment or
2419medical supplies by signage that can be read from 20 feet away.
2420The location must be readily accessible to the public during
2421normal, posted business hours and must operate at least 5 hours
2422per day and at least 5 days per week, with the exception of
2423scheduled and posted holidays. The location may not be located
2424within or at the same numbered street address as another
2425enrolled Medicaid durable medical equipment or medical supply
2426provider or as an enrolled Medicaid pharmacy that is also
2427enrolled as a durable medical equipment provider. A licensed
2428orthotist or prosthetist that provides only orthotic or
2429prosthetic devices as a Medicaid durable medical equipment
2430provider is exempt from this paragraph.
2431     6.  Providers must maintain a stock of durable medical
2432equipment and medical supplies on site that is readily available
2433to meet the needs of the durable medical equipment business
2434location's customers.
2435     7.  Providers must provide a surety bond of $50,000 for
2436each provider location, up to a maximum of 5 bonds statewide or
2437an aggregate bond of $250,000 statewide, as identified by
2438Federal Employer Identification Number. Providers who post a
2439statewide or an aggregate bond must identify all of their
2440locations in any Medicaid durable medical equipment and medical
2441supply provider enrollment application or bond renewal. Each
2442provider location's surety bond must be renewed annually and the
2443provider must submit proof of renewal even if the original bond
2444is a continuous bond. A licensed orthotist or prosthetist that
2445provides only orthotic or prosthetic devices as a Medicaid
2446durable medical equipment provider is exempt from the provisions
2447in this paragraph.
2448     8.  Providers must obtain a level 2 background screening,
2449in accordance with chapter 435 and s. 408.809, for each provider
2450employee in direct contact with or providing direct services to
2451recipients of durable medical equipment and medical supplies in
2452their homes. This requirement includes, but is not limited to,
2453repair and service technicians, fitters, and delivery staff. The
2454provider shall pay for the cost of the background screening.
2455     9.  The following providers are exempt from subparagraphs
24561. and 7.:
2457     a.  Durable medical equipment providers owned and operated
2458by a government entity.
2459     b.  Durable medical equipment providers that are operating
2460within a pharmacy that is currently enrolled as a Medicaid
2461pharmacy provider.
2462     c.  Active, Medicaid-enrolled orthopedic physician groups,
2463primarily owned by physicians, which provide only orthotic and
2464prosthetic devices.
2465     (45)(49)  The agency shall contract with established
2466minority physician networks that provide services to
2467historically underserved minority patients. The networks must
2468provide cost-effective Medicaid services, comply with the
2469requirements to be a MediPass provider, and provide their
2470primary care physicians with access to data and other management
2471tools necessary to assist them in ensuring the appropriate use
2472of services, including inpatient hospital services and
2474     (a)  The agency shall provide for the development and
2475expansion of minority physician networks in each service area to
2476provide services to Medicaid recipients who are eligible to
2477participate under federal law and rules.
2478     (b)  The agency shall reimburse each minority physician
2479network as a fee-for-service provider, including the case
2480management fee for primary care, if any, or as a capitated rate
2481provider for Medicaid services. Any savings shall be shared with
2482the minority physician networks pursuant to the contract.
2483     (c)  For purposes of this subsection, the term "cost-
2484effective" means that a network's per-member, per-month costs to
2485the state, including, but not limited to, fee-for-service costs,
2486administrative costs, and case-management fees, if any, must be
2487no greater than the state's costs associated with contracts for
2488Medicaid services established under subsection (3), which shall
2489be actuarially adjusted for case mix, model, and service area.
2490The agency shall conduct actuarially sound audits adjusted for
2491case mix and model in order to ensure such cost-effectiveness
2492and shall annually publish the audit results on its Internet
2493website. Contracts established pursuant to this subsection which
2494are not cost-effective may not be renewed.
2495     (d)  The agency may apply for any federal waivers needed to
2496implement this subsection.
2498This subsection expires October 1, 2014.
2499     (46)(50)  To the extent permitted by federal law and as
2500allowed under s. 409.906, the agency shall provide reimbursement
2501for emergency mental health care services for Medicaid
2502recipients in crisis stabilization facilities licensed under s.
2503394.875 as long as those services are less expensive than the
2504same services provided in a hospital setting.
2505     (47)(51)  The agency shall work with the Agency for Persons
2506with Disabilities to develop a home and community-based waiver
2507to serve children and adults who are diagnosed with familial
2508dysautonomia or Riley-Day syndrome caused by a mutation of the
2509IKBKAP gene on chromosome 9. The agency shall seek federal
2510waiver approval and implement the approved waiver subject to the
2511availability of funds and any limitations provided in the
2512General Appropriations Act. The agency may adopt rules to
2513implement this waiver program.
2514     (48)(52)  The agency shall implement a program of all-
2515inclusive care for children. The program of all-inclusive care
2516for children shall be established to provide in-home hospice-
2517like support services to children diagnosed with a life-
2518threatening illness and enrolled in the Children's Medical
2519Services network to reduce hospitalizations as appropriate. The
2520agency, in consultation with the Department of Health, may
2521implement the program of all-inclusive care for children after
2522obtaining approval from the Centers for Medicare and Medicaid
2524     (49)(53)  Before seeking an amendment to the state plan for
2525purposes of implementing programs authorized by the Deficit
2526Reduction Act of 2005, the agency shall notify the Legislature.
2527     Section 13.  Section 409.91207, Florida Statutes, is
2529     Section 14.  Paragraphs (e), (l), (p), (w), and (dd) of
2530subsection (3) of section 409.91211, Florida Statutes, are
2531amended to read:
2532     409.91211  Medicaid managed care pilot program.-
2533     (3)  The agency shall have the following powers, duties,
2534and responsibilities with respect to the pilot program:
2535     (e)  To implement policies and guidelines for phasing in
2536financial risk for approved provider service networks that, for
2537purposes of this paragraph, include the Children's Medical
2538Services Network, over the period of the waiver and the
2539extension thereof. These policies and guidelines must include an
2540option for a provider service network to be paid fee-for-service
2541rates. For any provider service network established in a managed
2542care pilot area, the option to be paid fee-for-service rates
2543must include a savings-settlement mechanism that is consistent
2544with s. 409.912(41)(44). This model must be converted to a risk-
2545adjusted capitated rate by the beginning of the final year of
2546operation under the waiver extension, and may be converted
2547earlier at the option of the provider service network. Federally
2548qualified health centers may be offered an opportunity to accept
2549or decline a contract to participate in any provider network for
2550prepaid primary care services.
2551     (l)  To implement a system that prohibits capitated managed
2552care plans, their representatives, and providers employed by or
2553contracted with the capitated managed care plans from recruiting
2554persons eligible for or enrolled in Medicaid, from providing
2555inducements to Medicaid recipients to select a particular
2556capitated managed care plan, and from prejudicing Medicaid
2557recipients against other capitated managed care plans. The
2558system shall require the entity performing choice counseling to
2559determine if the recipient has made a choice of a plan or has
2560opted out because of duress, threats, payment to the recipient,
2561or incentives promised to the recipient by a third party. If the
2562choice counseling entity determines that the decision to choose
2563a plan was unlawfully influenced or a plan violated any of the
2564provisions of s. 409.912(20)(21), the choice counseling entity
2565shall immediately report the violation to the agency's program
2566integrity section for investigation. Verification of choice
2567counseling by the recipient shall include a stipulation that the
2568recipient acknowledges the provisions of this subsection.
2569     (p)  To implement standards for plan compliance, including,
2570but not limited to, standards for quality assurance and
2571performance improvement, standards for peer or professional
2572reviews, grievance policies, and policies for maintaining
2573program integrity. The agency shall develop a data-reporting
2574system, seek input from managed care plans in order to establish
2575requirements for patient-encounter reporting, and ensure that
2576the data reported is accurate and complete.
2577     1.  In performing the duties required under this section,
2578the agency shall work with managed care plans to establish a
2579uniform system to measure and monitor outcomes for a recipient
2580of Medicaid services.
2581     2.  The system shall use financial, clinical, and other
2582criteria based on pharmacy, medical services, and other data
2583that is related to the provision of Medicaid services,
2584including, but not limited to:
2585     a.  The Health Plan Employer Data and Information Set
2586(HEDIS) or measures that are similar to HEDIS.
2587     b.  Member satisfaction.
2588     c.  Provider satisfaction.
2589     d.  Report cards on plan performance and best practices.
2590     e.  Compliance with the requirements for prompt payment of
2591claims under ss. 627.613, 641.3155, and 641.513.
2592     f.  Utilization and quality data for the purpose of
2593ensuring access to medically necessary services, including
2594underutilization or inappropriate denial of services.
2595     3.  The agency shall require the managed care plans that
2596have contracted with the agency to establish a quality assurance
2597system that incorporates the provisions of s. 409.912(26)(27)
2598and any standards, rules, and guidelines developed by the
2600     4.  The agency shall establish an encounter database in
2601order to compile data on health services rendered by health care
2602practitioners who provide services to patients enrolled in
2603managed care plans in the demonstration sites. The encounter
2604database shall:
2605     a.  Collect the following for each type of patient
2606encounter with a health care practitioner or facility,
2608     (I)  The demographic characteristics of the patient.
2609     (II)  The principal, secondary, and tertiary diagnosis.
2610     (III)  The procedure performed.
2611     (IV)  The date and location where the procedure was
2613     (V)  The payment for the procedure, if any.
2614     (VI)  If applicable, the health care practitioner's
2615universal identification number.
2616     (VII)  If the health care practitioner rendering the
2617service is a dependent practitioner, the modifiers appropriate
2618to indicate that the service was delivered by the dependent
2620     b.  Collect appropriate information relating to
2621prescription drugs for each type of patient encounter.
2622     c.  Collect appropriate information related to health care
2623costs and utilization from managed care plans participating in
2624the demonstration sites.
2625     5.  To the extent practicable, when collecting the data the
2626agency shall use a standardized claim form or electronic
2627transfer system that is used by health care practitioners,
2628facilities, and payors.
2629     6.  Health care practitioners and facilities in the
2630demonstration sites shall electronically submit, and managed
2631care plans participating in the demonstration sites shall
2632electronically receive, information concerning claims payments
2633and any other information reasonably related to the encounter
2634database using a standard format as required by the agency.
2635     7.  The agency shall establish reasonable deadlines for
2636phasing in the electronic transmittal of full encounter data.
2637     8.  The system must ensure that the data reported is
2638accurate and complete.
2639     (w)  To implement procedures to minimize the risk of
2640Medicaid fraud and abuse in all plans operating in the Medicaid
2641managed care pilot program authorized in this section.
2642     1.  The agency shall ensure that applicable provisions of
2643this chapter and chapters 414, 626, 641, and 932 which relate to
2644Medicaid fraud and abuse are applied and enforced at the
2645demonstration project sites.
2646     2.  Providers must have the certification, license, and
2647credentials that are required by law and waiver requirements.
2648     3.  The agency shall ensure that the plan is in compliance
2649with s. 409.912(20) and (21) and (22).
2650     4.  The agency shall require that each plan establish
2651functions and activities governing program integrity in order to
2652reduce the incidence of fraud and abuse. Plans must report
2653instances of fraud and abuse pursuant to chapter 641.
2654     5.  The plan shall have written administrative and
2655management arrangements or procedures, including a mandatory
2656compliance plan, which are designed to guard against fraud and
2657abuse. The plan shall designate a compliance officer who has
2658sufficient experience in health care.
2659     6.a.  The agency shall require all managed care plan
2660contractors in the pilot program to report all instances of
2661suspected fraud and abuse. A failure to report instances of
2662suspected fraud and abuse is a violation of law and subject to
2663the penalties provided by law.
2664     b.  An instance of fraud and abuse in the managed care
2665plan, including, but not limited to, defrauding the state health
2666care benefit program by misrepresentation of fact in reports,
2667claims, certifications, enrollment claims, demographic
2668statistics, or patient-encounter data; misrepresentation of the
2669qualifications of persons rendering health care and ancillary
2670services; bribery and false statements relating to the delivery
2671of health care; unfair and deceptive marketing practices; and
2672false claims actions in the provision of managed care, is a
2673violation of law and subject to the penalties provided by law.
2674     c.  The agency shall require that all contractors make all
2675files and relevant billing and claims data accessible to state
2676regulators and investigators and that all such data is linked
2677into a unified system to ensure consistent reviews and
2679     (dd)  To implement service delivery mechanisms within a
2680specialty plan in area 10 to provide behavioral health care
2681services to Medicaid-eligible children whose cases are open for
2682child welfare services in the HomeSafeNet system. These services
2683must be coordinated with community-based care providers as
2684specified in s. 409.1671, where available, and be sufficient to
2685meet the developmental, behavioral, and emotional needs of these
2686children. Children in area 10 who have an open case in the
2687HomeSafeNet system shall be enrolled into the specialty plan.
2688These service delivery mechanisms must be implemented no later
2689than July 1, 2011, in AHCA area 10 in order for the children in
2690AHCA area 10 to remain exempt from the statewide plan under s.
2691409.912(4)(b)5.8. An administrative fee may be paid to the
2692specialty plan for the coordination of services based on the
2693receipt of the state share of that fee being provided through
2694intergovernmental transfers.
2695     Section 15.  Effective October 1, 2014, section 409.91211,
2696Florida Statutes, is repealed.
2697     Section 16.  Section 409.9122, Florida Statutes, is amended
2698to read:
2699     409.9122  Mandatory Medicaid managed care enrollment;
2700programs and procedures.-
2701     (1)  It is the intent of the Legislature that the MediPass
2702program be cost-effective, provide quality health care, and
2703improve access to health services, and that the program be
2704statewide. This subsection expires October 1, 2014.
2705     (2)(a)  The agency shall enroll in a managed care plan or
2706MediPass all Medicaid recipients, except those Medicaid
2707recipients who are: in an institution; enrolled in the Medicaid
2708medically needy program; or eligible for both Medicaid and
2709Medicare. Upon enrollment, individuals will be able to change
2710their managed care option during the 90-day opt out period
2711required by federal Medicaid regulations. The agency is
2712authorized to seek the necessary Medicaid state plan amendment
2713to implement this policy. However, to the extent permitted by
2714federal law, the agency may enroll in a managed care plan or
2715MediPass a Medicaid recipient who is exempt from mandatory
2716managed care enrollment, provided that:
2717     1.  The recipient's decision to enroll in a managed care
2718plan or MediPass is voluntary;
2719     2.  If the recipient chooses to enroll in a managed care
2720plan, the agency has determined that the managed care plan
2721provides specific programs and services which address the
2722special health needs of the recipient; and
2723     3.  The agency receives any necessary waivers from the
2724federal Centers for Medicare and Medicaid Services.
2726The agency shall develop rules to establish policies by which
2727exceptions to the mandatory managed care enrollment requirement
2728may be made on a case-by-case basis. The rules shall include the
2729specific criteria to be applied when making a determination as
2730to whether to exempt a recipient from mandatory enrollment in a
2731managed care plan or MediPass. School districts participating in
2732the certified school match program pursuant to ss. 409.908(21)
2733and 1011.70 shall be reimbursed by Medicaid, subject to the
2734limitations of s. 1011.70(1), for a Medicaid-eligible child
2735participating in the services as authorized in s. 1011.70, as
2736provided for in s. 409.9071, regardless of whether the child is
2737enrolled in MediPass or a managed care plan. Managed care plans
2738shall make a good faith effort to execute agreements with school
2739districts regarding the coordinated provision of services
2740authorized under s. 1011.70. County health departments
2741delivering school-based services pursuant to ss. 381.0056 and
2742381.0057 shall be reimbursed by Medicaid for the federal share
2743for a Medicaid-eligible child who receives Medicaid-covered
2744services in a school setting, regardless of whether the child is
2745enrolled in MediPass or a managed care plan. Managed care plans
2746shall make a good faith effort to execute agreements with county
2747health departments regarding the coordinated provision of
2748services to a Medicaid-eligible child. To ensure continuity of
2749care for Medicaid patients, the agency, the Department of
2750Health, and the Department of Education shall develop procedures
2751for ensuring that a student's managed care plan or MediPass
2752provider receives information relating to services provided in
2753accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2754     (b)  A Medicaid recipient shall not be enrolled in or
2755assigned to a managed care plan or MediPass unless the managed
2756care plan or MediPass has complied with the quality-of-care
2757standards specified in paragraphs (3)(a) and (b), respectively.
2758     (c)  Medicaid recipients shall have a choice of managed
2759care plans or MediPass. The Agency for Health Care
2760Administration, the Department of Health, the Department of
2761Children and Family Services, and the Department of Elderly
2762Affairs shall cooperate to ensure that each Medicaid recipient
2763receives clear and easily understandable information that meets
2764the following requirements:
2765     1.  Explains the concept of managed care, including
2767     2.  Provides information on the comparative performance of
2768managed care plans and MediPass in the areas of quality,
2769credentialing, preventive health programs, network size and
2770availability, and patient satisfaction.
2771     3.  Explains where additional information on each managed
2772care plan and MediPass in the recipient's area can be obtained.
2773     4.  Explains that recipients have the right to choose their
2774managed care coverage at the time they first enroll in Medicaid
2775and again at regular intervals set by the agency. However, if a
2776recipient does not choose a managed care plan or MediPass, the
2777agency will assign the recipient to a managed care plan or
2778MediPass according to the criteria specified in this section.
2779     5.  Explains the recipient's right to complain, file a
2780grievance, or change managed care plans or MediPass providers if
2781the recipient is not satisfied with the managed care plan or
2783     (d)  The agency shall develop a mechanism for providing
2784information to Medicaid recipients for the purpose of making a
2785managed care plan or MediPass selection. Examples of such
2786mechanisms may include, but not be limited to, interactive
2787information systems, mailings, and mass marketing materials.
2788Managed care plans and MediPass providers are prohibited from
2789providing inducements to Medicaid recipients to select their
2790plans or from prejudicing Medicaid recipients against other
2791managed care plans or MediPass providers.
2792     (e)  Medicaid recipients who are already enrolled in a
2793managed care plan or MediPass shall be offered the opportunity
2794to change managed care plans or MediPass providers on a
2795staggered basis, as defined by the agency. All Medicaid
2796recipients shall have 30 days in which to make a choice of
2797managed care plans or MediPass providers. Those Medicaid
2798recipients who do not make a choice shall be assigned in
2799accordance with paragraph (f). To facilitate continuity of care,
2800for a Medicaid recipient who is also a recipient of Supplemental
2801Security Income (SSI), prior to assigning the SSI recipient to a
2802managed care plan or MediPass, the agency shall determine
2803whether the SSI recipient has an ongoing relationship with a
2804MediPass provider or managed care plan, and if so, the agency
2805shall assign the SSI recipient to that MediPass provider or
2806managed care plan. Those SSI recipients who do not have such a
2807provider relationship shall be assigned to a managed care plan
2808or MediPass provider in accordance with paragraph (f).
2809     (f)  If a Medicaid recipient does not choose a managed care
2810plan or MediPass provider, the agency shall assign the Medicaid
2811recipient to a managed care plan or MediPass provider. Medicaid
2812recipients eligible for managed care plan enrollment who are
2813subject to mandatory assignment but who fail to make a choice
2814shall be assigned to managed care plans until an enrollment of
281535 percent in MediPass and 65 percent in managed care plans, of
2816all those eligible to choose managed care, is achieved. Once
2817this enrollment is achieved, the assignments shall be divided in
2818order to maintain an enrollment in MediPass and managed care
2819plans which is in a 35 percent and 65 percent proportion,
2820respectively. Thereafter, assignment of Medicaid recipients who
2821fail to make a choice shall be based proportionally on the
2822preferences of recipients who have made a choice in the previous
2823period. Such proportions shall be revised at least quarterly to
2824reflect an update of the preferences of Medicaid recipients. The
2825agency shall disproportionately assign Medicaid-eligible
2826recipients who are required to but have failed to make a choice
2827of managed care plan or MediPass, including children, and who
2828would be assigned to the MediPass program to the children's
2829networks as described in s. 409.912(4)(g), Children's Medical
2830Services Network as defined in s. 391.021, exclusive provider
2831organizations, provider service networks, minority physician
2832networks, and pediatric emergency department diversion programs
2833authorized by this chapter or the General Appropriations Act, in
2834such manner as the agency deems appropriate, until the agency
2835has determined that the networks and programs have sufficient
2836numbers to be operated economically. For purposes of this
2837paragraph, when referring to assignment, the term "managed care
2838plans" includes health maintenance organizations, exclusive
2839provider organizations, provider service networks, minority
2840physician networks, Children's Medical Services Network, and
2841pediatric emergency department diversion programs authorized by
2842this chapter or the General Appropriations Act. When making
2843assignments, the agency shall take into account the following
2845     1.  A managed care plan has sufficient network capacity to
2846meet the need of members.
2847     2.  The managed care plan or MediPass has previously
2848enrolled the recipient as a member, or one of the managed care
2849plan's primary care providers or MediPass providers has
2850previously provided health care to the recipient.
2851     3.  The agency has knowledge that the member has previously
2852expressed a preference for a particular managed care plan or
2853MediPass provider as indicated by Medicaid fee-for-service
2854claims data, but has failed to make a choice.
2855     4.  The managed care plan's or MediPass primary care
2856providers are geographically accessible to the recipient's
2858     (g)  When more than one managed care plan or MediPass
2859provider meets the criteria specified in paragraph (f), the
2860agency shall make recipient assignments consecutively by family
2862     (h)  The agency may not engage in practices that are
2863designed to favor one managed care plan over another or that are
2864designed to influence Medicaid recipients to enroll in MediPass
2865rather than in a managed care plan or to enroll in a managed
2866care plan rather than in MediPass. This subsection does not
2867prohibit the agency from reporting on the performance of
2868MediPass or any managed care plan, as measured by performance
2869criteria developed by the agency.
2870     (i)  After a recipient has made his or her selection or has
2871been enrolled in a managed care plan or MediPass, the recipient
2872shall have 90 days to exercise the opportunity to voluntarily
2873disenroll and select another managed care plan or MediPass.
2874After 90 days, no further changes may be made except for good
2875cause. Good cause includes, but is not limited to, poor quality
2876of care, lack of access to necessary specialty services, an
2877unreasonable delay or denial of service, or fraudulent
2878enrollment. The agency shall develop criteria for good cause
2879disenrollment for chronically ill and disabled populations who
2880are assigned to managed care plans if more appropriate care is
2881available through the MediPass program. The agency must make a
2882determination as to whether cause exists. However, the agency
2883may require a recipient to use the managed care plan's or
2884MediPass grievance process prior to the agency's determination
2885of cause, except in cases in which immediate risk of permanent
2886damage to the recipient's health is alleged. The grievance
2887process, when utilized, must be completed in time to permit the
2888recipient to disenroll by the first day of the second month
2889after the month the disenrollment request was made. If the
2890managed care plan or MediPass, as a result of the grievance
2891process, approves an enrollee's request to disenroll, the agency
2892is not required to make a determination in the case. The agency
2893must make a determination and take final action on a recipient's
2894request so that disenrollment occurs no later than the first day
2895of the second month after the month the request was made. If the
2896agency fails to act within the specified timeframe, the
2897recipient's request to disenroll is deemed to be approved as of
2898the date agency action was required. Recipients who disagree
2899with the agency's finding that cause does not exist for
2900disenrollment shall be advised of their right to pursue a
2901Medicaid fair hearing to dispute the agency's finding.
2902     (j)  The agency shall apply for a federal waiver from the
2903Centers for Medicare and Medicaid Services to lock eligible
2904Medicaid recipients into a managed care plan or MediPass for 12
2905months after an open enrollment period. After 12 months'
2906enrollment, a recipient may select another managed care plan or
2907MediPass provider. However, nothing shall prevent a Medicaid
2908recipient from changing primary care providers within the
2909managed care plan or MediPass program during the 12-month
2911     (k)  When a Medicaid recipient does not choose a managed
2912care plan or MediPass provider, the agency shall assign the
2913Medicaid recipient to a managed care plan, except in those
2914counties in which there are fewer than two managed care plans
2915accepting Medicaid enrollees, in which case assignment shall be
2916to a managed care plan or a MediPass provider. Medicaid
2917recipients in counties with fewer than two managed care plans
2918accepting Medicaid enrollees who are subject to mandatory
2919assignment but who fail to make a choice shall be assigned to
2920managed care plans until an enrollment of 35 percent in MediPass
2921and 65 percent in managed care plans, of all those eligible to
2922choose managed care, is achieved. Once that enrollment is
2923achieved, the assignments shall be divided in order to maintain
2924an enrollment in MediPass and managed care plans which is in a
292535 percent and 65 percent proportion, respectively. For purposes
2926of this paragraph, when referring to assignment, the term
2927"managed care plans" includes exclusive provider organizations,
2928provider service networks, Children's Medical Services Network,
2929minority physician networks, and pediatric emergency department
2930diversion programs authorized by this chapter or the General
2931Appropriations Act. When making assignments, the agency shall
2932take into account the following criteria:
2933     1.  A managed care plan has sufficient network capacity to
2934meet the need of members.
2935     2.  The managed care plan or MediPass has previously
2936enrolled the recipient as a member, or one of the managed care
2937plan's primary care providers or MediPass providers has
2938previously provided health care to the recipient.
2939     3.  The agency has knowledge that the member has previously
2940expressed a preference for a particular managed care plan or
2941MediPass provider as indicated by Medicaid fee-for-service
2942claims data, but has failed to make a choice.
2943     4.  The managed care plan's or MediPass primary care
2944providers are geographically accessible to the recipient's
2946     5.  The agency has authority to make mandatory assignments
2947based on quality of service and performance of managed care
2949     (l)  Notwithstanding the provisions of chapter 287, the
2950agency may, at its discretion, renew cost-effective contracts
2951for choice counseling services once or more for such periods as
2952the agency may decide. However, all such renewals may not
2953combine to exceed a total period longer than the term of the
2954original contract.
2956This subsection expires October 1, 2014.
2957     (3)(a)  The agency shall establish quality-of-care
2958standards for managed care plans. These standards shall be based
2959upon, but are not limited to:
2960     1.  Compliance with the accreditation requirements as
2961provided in s. 641.512.
2962     2.  Compliance with Early and Periodic Screening,
2963Diagnosis, and Treatment screening requirements.
2964     3.  The percentage of voluntary disenrollments.
2965     4.  Immunization rates.
2966     5.  Standards of the National Committee for Quality
2967Assurance and other approved accrediting bodies.
2968     6.  Recommendations of other authoritative bodies.
2969     7.  Specific requirements of the Medicaid program, or
2970standards designed to specifically assist the unique needs of
2971Medicaid recipients.
2972     8.  Compliance with the health quality improvement system
2973as established by the agency, which incorporates standards and
2974guidelines developed by the Medicaid Bureau of the Health Care
2975Financing Administration as part of the quality assurance reform
2977     (b)  For the MediPass program, the agency shall establish
2978standards which are based upon, but are not limited to:
2979     1.  Quality-of-care standards which are comparable to those
2980required of managed care plans.
2981     2.  Credentialing standards for MediPass providers.
2982     3.  Compliance with Early and Periodic Screening,
2983Diagnosis, and Treatment screening requirements.
2984     4.  Immunization rates.
2985     5.  Specific requirements of the Medicaid program, or
2986standards designed to specifically assist the unique needs of
2987Medicaid recipients.
2989This subsection expires October 1, 2014.
2990     (4)(a)  Each female recipient may select as her primary
2991care provider an obstetrician/gynecologist who has agreed to
2992participate as a MediPass primary care case manager.
2993     (b)  The agency shall establish a complaints and grievance
2994process to assist Medicaid recipients enrolled in the MediPass
2995program to resolve complaints and grievances. The agency shall
2996investigate reports of quality-of-care grievances which remain
2997unresolved to the satisfaction of the enrollee.
2999This subsection expires October 1, 2014.
3000     (5)(a)  The agency shall work cooperatively with the Social
3001Security Administration to identify beneficiaries who are
3002jointly eligible for Medicare and Medicaid and shall develop
3003cooperative programs to encourage these beneficiaries to enroll
3004in a Medicare participating health maintenance organization or
3005prepaid health plans.
3006     (b)  The agency shall work cooperatively with the
3007Department of Elderly Affairs to assess the potential cost-
3008effectiveness of providing MediPass to beneficiaries who are
3009jointly eligible for Medicare and Medicaid on a voluntary choice
3010basis. If the agency determines that enrollment of these
3011beneficiaries in MediPass has the potential for being cost-
3012effective for the state, the agency shall offer MediPass to
3013these beneficiaries on a voluntary choice basis in the counties
3014where MediPass operates.
3016This subsection expires October 1, 2014.
3017     (6)  MediPass enrolled recipients may receive up to 10
3018visits of reimbursable services by participating Medicaid
3019physicians licensed under chapter 460 and up to four visits of
3020reimbursable services by participating Medicaid physicians
3021licensed under chapter 461. Any further visits must be by prior
3022authorization by the MediPass primary care provider. However,
3023nothing in this subsection may be construed to increase the
3024total number of visits or the total amount of dollars per year
3025per person under current Medicaid rules, unless otherwise
3026provided for in the General Appropriations Act. This subsection
3027expires October 1, 2014.
3028     (7)  The agency shall investigate the feasibility of
3029developing managed care plan and MediPass options for the
3030following groups of Medicaid recipients:
3031     (a)  Pregnant women and infants.
3032     (b)  Elderly and disabled recipients, especially those who
3033are at risk of nursing home placement.
3034     (c)  Persons with developmental disabilities.
3035     (d)  Qualified Medicare beneficiaries.
3036     (e)  Adults who have chronic, high-cost medical conditions.
3037     (f)  Adults and children who have mental health problems.
3038     (g)  Other recipients for whom managed care plans and
3039MediPass offer the opportunity of more cost-effective care and
3040greater access to qualified providers.
3041     (8)(a)  The agency shall encourage the development of
3042public and private partnerships to foster the growth of health
3043maintenance organizations and prepaid health plans that will
3044provide high-quality health care to Medicaid recipients.
3045     (b)  Subject to the availability of moneys and any
3046limitations established by the General Appropriations Act or
3047chapter 216, the agency is authorized to enter into contracts
3048with traditional providers of health care to low-income persons
3049to assist such providers with the technical aspects of
3050cooperatively developing Medicaid prepaid health plans.
3051     1.  The agency may contract with disproportionate share
3052hospitals, county health departments, federally initiated or
3053federally funded community health centers, and counties that
3054operate either a hospital or a community clinic.
3055     2.  A contract may not be for more than $100,000 per year,
3056and no contract may be extended with any particular provider for
3057more than 2 years. The contract is intended only as seed or
3058development funding and requires a commitment from the
3059interested party.
3060     3.  A contract must require participation by at least one
3061community health clinic and one disproportionate share hospital.
3062     (7)(9)(a)  The agency shall develop and implement a
3063comprehensive plan to ensure that recipients are adequately
3064informed of their choices and rights under all Medicaid managed
3065care programs and that Medicaid managed care programs meet
3066acceptable standards of quality in patient care, patient
3067satisfaction, and financial solvency.
3068     (b)  The agency shall provide adequate means for informing
3069patients of their choice and rights under a managed care plan at
3070the time of eligibility determination.
3071     (c)  The agency shall require managed care plans and
3072MediPass providers to demonstrate and document plans and
3073activities, as defined by rule, including outreach and followup,
3074undertaken to ensure that Medicaid recipients receive the health
3075care service to which they are entitled.
3077This subsection expires October 1, 2014.
3078     (8)(10)  The agency shall consult with Medicaid consumers
3079and their representatives on an ongoing basis regarding
3080measurements of patient satisfaction, procedures for resolving
3081patient grievances, standards for ensuring quality of care,
3082mechanisms for providing patient access to services, and
3083policies affecting patient care. This subsection expires October
30841, 2014.
3085     (9)(11)  The agency may extend eligibility for Medicaid
3086recipients enrolled in licensed and accredited health
3087maintenance organizations for the duration of the enrollment
3088period or for 6 months, whichever is earlier, provided the
3089agency certifies that such an offer will not increase state
3090expenditures. This subsection expires October 1, 2013.
3091     (10)(12)  A managed care plan that has a Medicaid contract
3092shall at least annually review each primary care physician's
3093active patient load and shall ensure that additional Medicaid
3094recipients are not assigned to physicians who have a total
3095active patient load of more than 3,000 patients. As used in this
3096subsection, the term "active patient" means a patient who is
3097seen by the same primary care physician, or by a physician
3098assistant or advanced registered nurse practitioner under the
3099supervision of the primary care physician, at least three times
3100within a calendar year. Each primary care physician shall
3101annually certify to the managed care plan whether or not his or
3102her patient load exceeds the limits established under this
3103subsection and the managed care plan shall accept such
3104certification on face value as compliance with this subsection.
3105The agency shall accept the managed care plan's representations
3106that it is in compliance with this subsection based on the
3107certification of its primary care physicians, unless the agency
3108has an objective indication that access to primary care is being
3109compromised, such as receiving complaints or grievances relating
3110to access to care. If the agency determines that an objective
3111indication exists that access to primary care is being
3112compromised, it may verify the patient load certifications
3113submitted by the managed care plan's primary care physicians and
3114that the managed care plan is not assigning Medicaid recipients
3115to primary care physicians who have an active patient load of
3116more than 3,000 patients. This subsection expires October 1,
3118     (11)(13)  Effective July 1, 2003, the agency shall adjust
3119the enrollee assignment process of Medicaid managed prepaid
3120health plans for those Medicaid managed prepaid plans operating
3121in Miami-Dade County which have executed a contract with the
3122agency for a minimum of 8 consecutive years in order for the
3123Medicaid managed prepaid plan to maintain a minimum enrollment
3124level of 15,000 members per month. When assigning enrollees
3125pursuant to this subsection, the agency shall give priority to
3126providers that initially qualified under this subsection until
3127such providers reach and maintain an enrollment level of 15,000
3128members per month. A prepaid health plan that has a statewide
3129Medicaid enrollment of 25,000 or more members is not eligible
3130for enrollee assignments under this subsection. This subsection
3131expires October 1, 2014.
3132     (12)(14)  The agency shall include in its calculation of
3133the hospital inpatient component of a Medicaid health
3134maintenance organization's capitation rate any special payments,
3135including, but not limited to, upper payment limit or
3136disproportionate share hospital payments, made to qualifying
3137hospitals through the fee-for-service program. The agency may
3138seek federal waiver approval or state plan amendment as needed
3139to implement this adjustment.
3140     (13)  The agency shall develop a process to enable any
3141recipient with access to employer-sponsored health care coverage
3142to opt out of all eligible plans in the Medicaid program and to
3143use Medicaid financial assistance to pay for the recipient's
3144share of cost in any such employer-sponsored coverage.
3145Contingent on federal approval, the agency shall also enable
3146recipients with access to other insurance or related products
3147that provide access to health care services created pursuant to
3148state law, including any plan or product available pursuant to
3149the Florida Health Choices Program or any health exchange, to
3150opt out. The amount of financial assistance provided for each
3151recipient may not exceed the amount of the Medicaid premium that
3152would have been paid to a plan for that recipient.
3153     (14)  The agency shall maintain and operate the Medicaid
3154Encounter Data System to collect, process, store, and report on
3155covered services provided to all Florida Medicaid recipients
3156enrolled in prepaid managed care plans.
3157     (a)  Prepaid managed care plans shall submit encounter data
3158electronically in a format that complies with the Health
3159Insurance Portability and Accountability Act provisions for
3160electronic claims and in accordance with deadlines established
3161by the agency. Prepaid managed care plans must certify that the
3162data reported is accurate and complete.
3163     (b)  The agency is responsible for validating the data
3164submitted by the plans. The agency shall develop methods and
3165protocols for ongoing analysis of the encounter data that
3166adjusts for differences in characteristics of prepaid plan
3167enrollees to allow comparison of service utilization among plans
3168and against expected levels of use. The analysis shall be used
3169to identify possible cases of systemic underutilization or
3170denials of claims and inappropriate service utilization such as
3171higher-than-expected emergency department encounters. The
3172analysis shall provide periodic feedback to the plans and enable
3173the agency to establish corrective action plans when necessary.
3174One of the focus areas for the analysis shall be the use of
3175prescription drugs.
3176     (15)  The agency may establish a per-member, per-month
3177payment for Medicare Advantage Special Needs members that are
3178also eligible for Medicaid as a mechanism for meeting the
3179state's cost-sharing obligation. The agency may also develop a
3180per-member, per-month payment only for Medicaid-covered services
3181for which the state is responsible. The agency shall develop a
3182mechanism to ensure that such per-member, per-month payment
3183enhances the value to the state and enrolled members by limiting
3184cost sharing, enhances the scope of Medicare supplemental
3185benefits that are equal to or greater than Medicaid coverage for
3186select services, and improves care coordination.
3187     (16)  The agency shall establish, and managed care plans
3188shall use, a uniform method of accounting for and reporting
3189medical and nonmedical costs. The agency shall make such
3190information available to the public.
3191     (17)  The agency may, on a case-by-case basis, exempt a
3192recipient from mandatory enrollment in a managed care plan when
3193the recipient has a unique, time-limited disease or condition-
3194related circumstance and managed care enrollment will interfere
3195with ongoing care because the recipient's provider does not
3196participate in the managed care plans available in the
3197recipient's area.
3198     (18)  The agency shall contract with a single provider
3199service network to function as a third-party administrator and
3200managing entity for the MediPass program in all counties with
3201fewer than two prepaid plans. The contractor may earn an
3202administrative fee, if the fee is less than any savings
3203determined by the reconciliation process pursuant to s.
3204409.912(4)(d)1. This subsection expires October 1, 2014, or upon
3205full implementation of the managed medical assistance program,
3206whichever is sooner.
3207     Section 17.  Subsection (15) of section 430.04, Florida
3208Statutes, is amended to read:
3209     430.04  Duties and responsibilities of the Department of
3210Elderly Affairs.-The Department of Elderly Affairs shall:
3211     (15)  Administer all Medicaid waivers and programs relating
3212to elders and their appropriations. The waivers include, but are
3213not limited to:
3214     (a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3215established in s. 430.502(7), (8), and (9).
3216     (a)(b)  The Assisted Living for the Frail Elderly Waiver.
3217     (b)(c)  The Aged and Disabled Adult Waiver.
3218     (c)(d)  The Adult Day Health Care Waiver.
3219     (d)(e)  The Consumer-Directed Care Plus Program as defined
3220in s. 409.221.
3221     (e)(f)  The Program of All-inclusive Care for the Elderly.
3222     (f)(g)  The Long-Term Care Community-Based Diversion Pilot
3223Project as described in s. 430.705.
3224     (g)(h)  The Channeling Services Waiver for Frail Elders.
3226The department shall develop a transition plan for recipients
3227receiving services in long-term care Medicaid waivers for elders
3228or disabled adults on the date eligible plans become available
3229in each recipient's region defined in s. 409.981(2) to enroll
3230those recipients in eligible plans. This subsection expires
3231October 1, 2013.
3232     Section 18.  Section 430.2053, Florida Statutes, is amended
3233to read:
3234     430.2053  Aging resource centers.-
3235     (1)  The department, in consultation with the Agency for
3236Health Care Administration and the Department of Children and
3237Family Services, shall develop pilot projects for aging resource
3238centers. By October 31, 2004, the department, in consultation
3239with the agency and the Department of Children and Family
3240Services, shall develop an implementation plan for aging
3241resource centers and submit the plan to the Governor, the
3242President of the Senate, and the Speaker of the House of
3243Representatives. The plan must include qualifications for
3244designation as a center, the functions to be performed by each
3245center, and a process for determining that a current area agency
3246on aging is ready to assume the functions of an aging resource
3248     (2)  Each area agency on aging shall develop, in
3249consultation with the existing community care for the elderly
3250lead agencies within their planning and service areas, a
3251proposal that describes the process the area agency on aging
3252intends to undertake to transition to an aging resource center
3253prior to July 1, 2005, and that describes the area agency's
3254compliance with the requirements of this section. The proposals
3255must be submitted to the department prior to December 31, 2004.
3256The department shall evaluate all proposals for readiness and,
3257prior to March 1, 2005, shall select three area agencies on
3258aging which meet the requirements of this section to begin the
3259transition to aging resource centers. Those area agencies on
3260aging which are not selected to begin the transition to aging
3261resource centers shall, in consultation with the department and
3262the existing community care for the elderly lead agencies within
3263their planning and service areas, amend their proposals as
3264necessary and resubmit them to the department prior to July 1,
32652005. The department may transition additional area agencies to
3266aging resource centers as it determines that area agencies are
3267in compliance with the requirements of this section.
3268     (3)  The Auditor General and the Office of Program Policy
3269Analysis and Government Accountability (OPPAGA) shall jointly
3270review and assess the department's process for determining an
3271area agency's readiness to transition to an aging resource
3273     (a)  The review must, at a minimum, address the
3274appropriateness of the department's criteria for selection of an
3275area agency to transition to an aging resource center, the
3276instruments applied, the degree to which the department
3277accurately determined each area agency's compliance with the
3278readiness criteria, the quality of the technical assistance
3279provided by the department to an area agency in correcting any
3280weaknesses identified in the readiness assessment, and the
3281degree to which each area agency overcame any identified
3283     (b)  Reports of these reviews must be submitted to the
3284appropriate substantive and appropriations committees in the
3285Senate and the House of Representatives on March 1 and September
32861 of each year until full transition to aging resource centers
3287has been accomplished statewide, except that the first report
3288must be submitted by February 1, 2005, and must address all
3289readiness activities undertaken through December 31, 2004. The
3290perspectives of all participants in this review process must be
3291included in each report.
3292     (2)(4)  The purposes of an aging resource center shall be:
3293     (a)  To provide Florida's elders and their families with a
3294locally focused, coordinated approach to integrating information
3295and referral for all available services for elders with the
3296eligibility determination entities for state and federally
3297funded long-term-care services.
3298     (b)  To provide for easier access to long-term-care
3299services by Florida's elders and their families by creating
3300multiple access points to the long-term-care network that flow
3301through one established entity with wide community recognition.
3302     (3)(5)  The duties of an aging resource center are to:
3303     (a)  Develop referral agreements with local community
3304service organizations, such as senior centers, existing elder
3305service providers, volunteer associations, and other similar
3306organizations, to better assist clients who do not need or do
3307not wish to enroll in programs funded by the department or the
3308agency. The referral agreements must also include a protocol,
3309developed and approved by the department, which provides
3310specific actions that an aging resource center and local
3311community service organizations must take when an elder or an
3312elder's representative seeking information on long-term-care
3313services contacts a local community service organization prior
3314to contacting the aging resource center. The protocol shall be
3315designed to ensure that elders and their families are able to
3316access information and services in the most efficient and least
3317cumbersome manner possible.
3318     (b)  Provide an initial screening of all clients who
3319request long-term-care services to determine whether the person
3320would be most appropriately served through any combination of
3321federally funded programs, state-funded programs, locally funded
3322or community volunteer programs, or private funding for
3324     (c)  Determine eligibility for the programs and services
3325listed in subsection (9) (11) for persons residing within the
3326geographic area served by the aging resource center and
3327determine a priority ranking for services which is based upon
3328the potential recipient's frailty level and likelihood of
3329institutional placement without such services.
3330     (d)  Manage the availability of financial resources for the
3331programs and services listed in subsection (9) (11) for persons
3332residing within the geographic area served by the aging resource
3334     (e)  When financial resources become available, refer a
3335client to the most appropriate entity to begin receiving
3336services. The aging resource center shall make referrals to lead
3337agencies for service provision that ensure that individuals who
3338are vulnerable adults in need of services pursuant to s.
3339415.104(3)(b), or who are victims of abuse, neglect, or
3340exploitation in need of immediate services to prevent further
3341harm and are referred by the adult protective services program,
3342are given primary consideration for receiving community-care-
3343for-the-elderly services in compliance with the requirements of
3344s. 430.205(5)(a) and that other referrals for services are in
3345compliance with s. 430.205(5)(b).
3346     (f)  Convene a work group to advise in the planning,
3347implementation, and evaluation of the aging resource center. The
3348work group shall be comprised of representatives of local
3349service providers, Alzheimer's Association chapters, housing
3350authorities, social service organizations, advocacy groups,
3351representatives of clients receiving services through the aging
3352resource center, and any other persons or groups as determined
3353by the department. The aging resource center, in consultation
3354with the work group, must develop annual program improvement
3355plans that shall be submitted to the department for
3356consideration. The department shall review each annual
3357improvement plan and make recommendations on how to implement
3358the components of the plan.
3359     (g)  Enhance the existing area agency on aging in each
3360planning and service area by integrating, either physically or
3361virtually, the staff and services of the area agency on aging
3362with the staff of the department's local CARES Medicaid nursing
3363home preadmission screening unit and a sufficient number of
3364staff from the Department of Children and Family Services'
3365Economic Self-Sufficiency Unit necessary to determine the
3366financial eligibility for all persons age 60 and older residing
3367within the area served by the aging resource center that are
3368seeking Medicaid services, Supplemental Security Income, and
3369food assistance.
3370     (h)  Assist clients who request long-term care services in
3371being evaluated for eligibility for enrollment in the Medicaid
3372long-term care managed care program as eligible plans become
3373available in each of the regions pursuant to s. 409.981(2).
3374     (i)  Provide choice counseling for the Medicaid long-term
3375care managed care program by integrating, either physically or
3376virtually, choice counseling staff and services as eligible
3377plans become available in each of the regions pursuant to s.
3378409.981(2). Pursuant to s. 409.984(1), the agency may contract
3379directly with the aging resource center to provide choice
3380counseling services or may contract with another vendor if the
3381aging resource center does not choose to provide such services.
3382     (j)  Assist Medicaid recipients enrolled in the Medicaid
3383long-term care managed care program with informally resolving
3384grievances with a managed care network and assist Medicaid
3385recipients in accessing the managed care network's formal
3386grievance process as eligible plans become available in each of
3387the regions defined in s. 409.981(2).
3388     (4)(6)  The department shall select the entities to become
3389aging resource centers based on each entity's readiness and
3390ability to perform the duties listed in subsection (3) (5) and
3391the entity's:
3392     (a)  Expertise in the needs of each target population the
3393center proposes to serve and a thorough knowledge of the
3394providers that serve these populations.
3395     (b)  Strong connections to service providers, volunteer
3396agencies, and community institutions.
3397     (c)  Expertise in information and referral activities.
3398     (d)  Knowledge of long-term-care resources, including
3399resources designed to provide services in the least restrictive
3401     (e)  Financial solvency and stability.
3402     (f)  Ability to collect, monitor, and analyze data in a
3403timely and accurate manner, along with systems that meet the
3404department's standards.
3405     (g)  Commitment to adequate staffing by qualified personnel
3406to effectively perform all functions.
3407     (h)  Ability to meet all performance standards established
3408by the department.
3409     (5)(7)  The aging resource center shall have a governing
3410body which shall be the same entity described in s. 20.41(7),
3411and an executive director who may be the same person as
3412described in s. 20.41(7). The governing body shall annually
3413evaluate the performance of the executive director.
3414     (6)(8)  The aging resource center may not be a provider of
3415direct services other than choice counseling as eligible plans
3416become available in each of the regions defined in s.
3417409.981(2), information and referral services, and screening.
3418     (7)(9)  The aging resource center must agree to allow the
3419department to review any financial information the department
3420determines is necessary for monitoring or reporting purposes,
3421including financial relationships.
3422     (8)(10)  The duties and responsibilities of the community
3423care for the elderly lead agencies within each area served by an
3424aging resource center shall be to:
3425     (a)  Develop strong community partnerships to maximize the
3426use of community resources for the purpose of assisting elders
3427to remain in their community settings for as long as it is
3428safely possible.
3429     (b)  Conduct comprehensive assessments of clients that have
3430been determined eligible and develop a care plan consistent with
3431established protocols that ensures that the unique needs of each
3432client are met.
3433     (9)(11)  The services to be administered through the aging
3434resource center shall include those funded by the following
3436     (a)  Community care for the elderly.
3437     (b)  Home care for the elderly.
3438     (c)  Contracted services.
3439     (d)  Alzheimer's disease initiative.
3440     (e)  Aged and disabled adult Medicaid waiver. This
3441paragraph expires October 1, 2013.
3442     (f)  Assisted living for the frail elderly Medicaid waiver.
3443This paragraph expires October 1, 2013.
3444     (g)  Older Americans Act.
3445     (10)(12)  The department shall, prior to designation of an
3446aging resource center, develop by rule operational and quality
3447assurance standards and outcome measures to ensure that clients
3448receiving services through all long-term-care programs
3449administered through an aging resource center are receiving the
3450appropriate care they require and that contractors and
3451subcontractors are adhering to the terms of their contracts and
3452are acting in the best interests of the clients they are
3453serving, consistent with the intent of the Legislature to reduce
3454the use of and cost of nursing home care. The department shall
3455by rule provide operating procedures for aging resource centers,
3456which shall include:
3457     (a)  Minimum standards for financial operation, including
3458audit procedures.
3459     (b)  Procedures for monitoring and sanctioning of service
3461     (c)  Minimum standards for technology utilized by the aging
3462resource center.
3463     (d)  Minimum staff requirements which shall ensure that the
3464aging resource center employs sufficient quality and quantity of
3465staff to adequately meet the needs of the elders residing within
3466the area served by the aging resource center.
3467     (e)  Minimum accessibility standards, including hours of
3469     (f)  Minimum oversight standards for the governing body of
3470the aging resource center to ensure its continuous involvement
3471in, and accountability for, all matters related to the
3472development, implementation, staffing, administration, and
3473operations of the aging resource center.
3474     (g)  Minimum education and experience requirements for
3475executive directors and other executive staff positions of aging
3476resource centers.
3477     (h)  Minimum requirements regarding any executive staff
3478positions that the aging resource center must employ and minimum
3479requirements that a candidate must meet in order to be eligible
3480for appointment to such positions.
3481     (11)(13)  In an area in which the department has designated
3482an area agency on aging as an aging resource center, the
3483department and the agency shall not make payments for the
3484services listed in subsection (9) (11) and the Long-Term Care
3485Community Diversion Project for such persons who were not
3486screened and enrolled through the aging resource center. The
3487department shall cease making payments for recipients in
3488eligible plans as eligible plans become available in each of the
3489regions defined in s. 409.981(2).
3490     (12)(14)  Each aging resource center shall enter into a
3491memorandum of understanding with the department for
3492collaboration with the CARES unit staff. The memorandum of
3493understanding shall outline the staff person responsible for
3494each function and shall provide the staffing levels necessary to
3495carry out the functions of the aging resource center.
3496     (13)(15)  Each aging resource center shall enter into a
3497memorandum of understanding with the Department of Children and
3498Family Services for collaboration with the Economic Self-
3499Sufficiency Unit staff. The memorandum of understanding shall
3500outline which staff persons are responsible for which functions
3501and shall provide the staffing levels necessary to carry out the
3502functions of the aging resource center.
3503     (14)  As eligible plans become available in each of the
3504regions defined in s. 409.981(2), if an aging resource center
3505does not contract with the agency to provide Medicaid long-term
3506care managed care choice counseling pursuant to s. 409.984(1),
3507the aging resource center shall enter into a memorandum of
3508understanding with the agency to coordinate staffing and
3509collaborate with the choice counseling vendor. The memorandum of
3510understanding shall identify the staff responsible for each
3511function and shall provide the staffing levels necessary to
3512carry out the functions of the aging resource center.
3513     (15)(16)  If any of the state activities described in this
3514section are outsourced, either in part or in whole, the contract
3515executing the outsourcing shall mandate that the contractor or
3516its subcontractors shall, either physically or virtually,
3517execute the provisions of the memorandum of understanding
3518instead of the state entity whose function the contractor or
3519subcontractor now performs.
3520     (16)(17)  In order to be eligible to begin transitioning to
3521an aging resource center, an area agency on aging board must
3522ensure that the area agency on aging which it oversees meets all
3523of the minimum requirements set by law and in rule.
3524     (18)  The department shall monitor the three initial
3525projects for aging resource centers and report on the progress
3526of those projects to the Governor, the President of the Senate,
3527and the Speaker of the House of Representatives by June 30,
35282005. The report must include an evaluation of the
3529implementation process.
3530     (17)(19)(a)  Once an aging resource center is operational,
3531the department, in consultation with the agency, may develop
3532capitation rates for any of the programs administered through
3533the aging resource center. Capitation rates for programs shall
3534be based on the historical cost experience of the state in
3535providing those same services to the population age 60 or older
3536residing within each area served by an aging resource center.
3537Each capitated rate may vary by geographic area as determined by
3538the department.
3539     (b)  The department and the agency may determine for each
3540area served by an aging resource center whether it is
3541appropriate, consistent with federal and state laws and
3542regulations, to develop and pay separate capitated rates for
3543each program administered through the aging resource center or
3544to develop and pay capitated rates for service packages which
3545include more than one program or service administered through
3546the aging resource center.
3547     (c)  Once capitation rates have been developed and
3548certified as actuarially sound, the department and the agency
3549may pay service providers the capitated rates for services when
3551     (d)  The department, in consultation with the agency, shall
3552annually reevaluate and recertify the capitation rates,
3553adjusting forward to account for inflation, programmatic
3555     (20)  The department, in consultation with the agency,
3556shall submit to the Governor, the President of the Senate, and
3557the Speaker of the House of Representatives, by December 1,
35582006, a report addressing the feasibility of administering the
3559following services through aging resource centers beginning July
35601, 2007:
3561     (a)  Medicaid nursing home services.
3562     (b)  Medicaid transportation services.
3563     (c)  Medicaid hospice care services.
3564     (d)  Medicaid intermediate care services.
3565     (e)  Medicaid prescribed drug services.
3566     (f)  Medicaid assistive care services.
3567     (g)  Any other long-term-care program or Medicaid service.
3568     (18)(21)  This section shall not be construed to allow an
3569aging resource center to restrict, manage, or impede the local
3570fundraising activities of service providers.
3571     Section 19.  Effective October 1, 2013, sections 430.701,
3572430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3573430.708, and 430.709, Florida Statutes, are repealed.
3574     Section 20.  Sections 409.9301, 409.942, 409.944, 409.945,
3575409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3576as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3577402.87, Florida Statutes, respectively.
3578     Section 21.  Paragraph (a) of subsection (1) of section
3579443.111, Florida Statutes, is amended to read:
3580     443.111  Payment of benefits.-
3581     (1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3582in accordance with rules adopted by the Agency for Workforce
3583Innovation, subject to the following requirements:
3584     (a)  Benefits are payable by mail or electronically.
3585Notwithstanding s. 402.84(4) s. 409.942(4), the agency may
3586develop a system for the payment of benefits by electronic funds
3587transfer, including, but not limited to, debit cards, electronic
3588payment cards, or any other means of electronic payment that the
3589agency deems to be commercially viable or cost-effective.
3590Commodities or services related to the development of such a
3591system shall be procured by competitive solicitation, unless
3592they are purchased from a state term contract pursuant to s.
3593287.056. The agency shall adopt rules necessary to administer
3594the system.
3595     Section 22.  Subsection (4) of section 641.386, Florida
3596Statutes, is amended to read:
3597     641.386  Agent licensing and appointment required;
3599     (4)  All agents and health maintenance organizations shall
3600comply with and be subject to the applicable provisions of ss.
3601641.309 and 409.912(20)(21), and all companies and entities
3602appointing agents shall comply with s. 626.451, when marketing
3603for any health maintenance organization licensed pursuant to
3604this part, including those organizations under contract with the
3605Agency for Health Care Administration to provide health care
3606services to Medicaid recipients or any private entity providing
3607health care services to Medicaid recipients pursuant to a
3608prepaid health plan contract with the Agency for Health Care
3610     Section 23.  The Agency for Health Care Administration
3611shall develop a plan for implementing s. 409.975(8), Florida
3612Statutes, and shall immediately seek federal approval to
3613implement that subsection. The plan shall include a preliminary
3614calculation of actuarially sound rates and estimated fiscal
3616     Section 24.  Except as otherwise expressly provided in this
3617act, this act shall take effect July 1, 2011, if HB 7107 or
3618similar legislation is adopted in the same legislative session
3619or an extension thereof and becomes law.

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