CS/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. 409.907, F.S.; providing
41additional requirements for provider agreements for
42Medicare crossover providers; providing that the agency is
43not obligated to enroll certain providers as Medicare
44crossover providers; specifying additional requirements
45for certain providers; providing the agency may establish
46additional criteria for providers to promote program
47integrity; amending s. 409.911, F.S.; providing for
48expiration of the Medicaid Low-Income Pool Council;
49amending s. 409.912, F.S.; providing payment requirements
50for provider service networks; providing for the
51expiration of various provisions relating to agency
52contracts and agreements with certain entities on
53specified dates to conform to the reorganization of
54Medicaid managed care; requiring the agency to contract on
55a prepaid or fixed-sum basis with certain prepaid dental
56health plans; eliminating obsolete provisions and updating
57provisions, to conform; amending ss. 409.91195 and
58409.91196, F.S.; conforming cross-references; repealing s.
59409.91207, F.S., relating to the medical home pilot
60project; amending s. 409.91211, F.S.; conforming cross-
61references; providing for future repeal of s. 409.91211,
62F.S., relating to the Medicaid managed care pilot program;
63amending s. 409.9122, F.S.; providing for the expiration
64of provisions relating to mandatory enrollment in a
65Medicaid managed care plan or MediPass on specified dates
66to conform to the reorganization of Medicaid managed care;
67eliminating obsolete provisions; requiring the agency to
68develop a process to enable any recipient with access to
69employer-sponsored coverage to opt out of eligible plans
70in the Medicaid program; requiring the agency, contingent
71on federal approval, to enable recipients with access to
72other coverage or related products that provide access to
73specified health care services to opt out of eligible
74plans in the Medicaid program; requiring the agency to
75maintain and operate the Medicaid Encounter Data System;
76requiring the agency to conduct a review of encounter data
77and publish the results of the review before adjusting
78rates for prepaid plans; authorizing the agency to
79establish a designated payment for specified Medicare
80Advantage Special Needs members; authorizing the agency to
81develop a designated payment for Medicaid-only covered
82services for which the state is responsible; requiring the
83agency to establish, and managed care plans to use, a
84uniform method of accounting for and reporting medical and
85nonmedical costs; authorizing the agency to create
86exceptions to mandatory enrollment in managed care under
87specified circumstances; requiring the agency to contract
88with a provider service network to function as a third-
89party administrator and managing entity for the MediPass
90program; providing contract provisions; providing for the
91expiration of such contract requirements on a specified
92date; requiring the agency to contract with a single
93provider service network to function as a third-party
94administrator and managing entity for the Medically Needy
95program; providing contract provisions; providing for the
96expiration of such contract requirements on a specified
97date; amending s. 430.04, F.S.; eliminating obsolete
98provisions; requiring the Department of Elderly Affairs to
99develop a transition plan for specified elders and
100disabled adults receiving long-term care Medicaid services
101when eligible plans become available; providing for
102expiration of the plan; amending s. 430.2053, F.S.;
103eliminating obsolete provisions; providing additional
104duties of aging resource centers; providing an additional
105exception to direct services that may not be provided by
106an aging resource center; providing an expiration date for
107certain services administered through aging resource
108centers; providing for the cessation of specified payments
109by the department as eligible plans become available;
110providing for a memorandum of understanding between the
111agency and aging resource centers under certain
112circumstances; eliminating provisions requiring reports;
113repealing s. 430.701, F.S., relating to legislative
114findings and intent and approval for action relating to
115provider enrollment levels; repealing s. 430.702, F.S.,
116relating to the Long-Term Care Community Diversion Pilot
117Project Act; repealing s. 430.703, F.S., relating to
118definitions; repealing s. 430.7031, F.S., relating to the
119nursing home transition program; repealing s. 430.704,
120F.S., relating to evaluation of long-term care through the
121pilot projects; repealing s. 430.705, F.S., relating to
122implementation of long-term care community diversion pilot
123projects; repealing s. 430.706, F.S., relating to quality
124of care; repealing s. 430.707, F.S., relating to
125contracts; repealing s. 430.708, F.S., relating to
126certificate of need; repealing s. 430.709, F.S., relating
127to reports and evaluations; renumbering ss. 409.9301,
128409.942, 409.944, 409.945, 409.946, 409.953, and 409.9531,
129F.S., as ss. 402.81, 402.82, 402.83, 402.84, 402.85,
130402.86, and 402.87, F.S., respectively; amending ss.
131443.111 and 641.386, F.S.; conforming cross-references;
132directing the agency to develop a plan to implement the
133enrollment of the medically needy into managed care;
134amending s. 766.118, F.S.; providing a limitation on
135noneconomic damages for negligence of practitioners
136providing services and care to Medicaid recipients;
137providing effective dates and a contingent effective date.
139Be It Enacted by the Legislature of the State of Florida:
141     Section 1.  Section 393.0661, Florida Statutes, is amended
142to read:
143     393.0661  Home and community-based services delivery
144system; comprehensive redesign.-The Legislature finds that the
145home and community-based services delivery system for persons
146with developmental disabilities and the availability of
147appropriated funds are two of the critical elements in making
148services available. Therefore, it is the intent of the
149Legislature that the Agency for Persons with Disabilities shall
150develop and implement a comprehensive redesign of the system.
151     (1)  The redesign of the home and community-based services
152system shall include, at a minimum, all actions necessary to
153achieve an appropriate rate structure, client choice within a
154specified service package, appropriate assessment strategies, an
155efficient billing process that contains reconciliation and
156monitoring components, and a redefined role for support
157coordinators that avoids potential conflicts of interest and
158ensures that family/client budgets are linked to levels of need.
159     (a)  The agency shall use an assessment instrument that the
160agency deems to be reliable and valid, including, but not
161limited to, the Department of Children and Family Services'
162Individual Cost Guidelines or the agency's Questionnaire for
163Situational Information. The agency may contract with an
164external vendor or may use support coordinators to complete
165client assessments if it develops sufficient safeguards and
166training to ensure ongoing inter-rater reliability.
167     (b)  The agency, with the concurrence of the Agency for
168Health Care Administration, may contract for the determination
169of medical necessity and establishment of individual budgets.
170     (2)  A provider of services rendered to persons with
171developmental disabilities pursuant to a federally approved
172waiver shall be reimbursed according to a rate methodology based
173upon an analysis of the expenditure history and prospective
174costs of providers participating in the waiver program, or under
175any other methodology developed by the Agency for Health Care
176Administration, in consultation with the Agency for Persons with
177Disabilities, and approved by the Federal Government in
178accordance with the waiver.
179     (3)  The Agency for Health Care Administration, in
180consultation with the agency, shall seek federal approval and
181implement a four-tiered waiver system to serve eligible clients
182through the developmental disabilities and family and supported
183living waivers. The agency shall assign all clients receiving
184services through the developmental disabilities waiver to a tier
185based on the Department of Children and Family Services'
186Individual Cost Guidelines, the agency's Questionnaire for
187Situational Information, or another such assessment instrument
188deemed to be valid and reliable by the agency; client
189characteristics, including, but not limited to, age; and other
190appropriate assessment methods.
191     (a)  Tier one is limited to clients who have service needs
192that cannot be met in tier two, three, or four for intensive
193medical or adaptive needs and that are essential for avoiding
194institutionalization, or who possess behavioral problems that
195are exceptional in intensity, duration, or frequency and present
196a substantial risk of harm to themselves or others. Total annual
197expenditures under tier one may not exceed $150,000 per client
198each year, provided that expenditures for clients in tier one
199with a documented medical necessity requiring intensive
200behavioral residential habilitation services, intensive
201behavioral residential habilitation services with medical needs,
202or special medical home care, as provided in the Developmental
203Disabilities Waiver Services Coverage and Limitations Handbook,
204are not subject to the $150,000 limit on annual expenditures.
205     (b)  Tier two is limited to clients whose service needs
206include a licensed residential facility and who are authorized
207to receive a moderate level of support for standard residential
208habilitation services or a minimal level of support for behavior
209focus residential habilitation services, or clients in supported
210living who receive more than 6 hours a day of in-home support
211services. Total annual expenditures under tier two may not
212exceed $53,625 per client each year.
213     (c)  Tier three includes, but is not limited to, clients
214requiring residential placements, clients in independent or
215supported living situations, and clients who live in their
216family home. Total annual expenditures under tier three may not
217exceed $34,125 per client each year.
218     (d)  Tier four includes individuals who were enrolled in
219the family and supported living waiver on July 1, 2007, who
220shall be assigned to this tier without the assessments required
221by this section. Tier four also includes, but is not limited to,
222clients in independent or supported living situations and
223clients who live in their family home. Total annual expenditures
224under tier four may not exceed $14,422 per client each year.
225     (e)  The Agency for Health Care Administration shall also
226seek federal approval to provide a consumer-directed option for
227persons with developmental disabilities which corresponds to the
228funding levels in each of the waiver tiers. The agency shall
229implement the four-tiered waiver system beginning with tiers
230one, three, and four and followed by tier two. The agency and
231the Agency for Health Care Administration may adopt rules
232necessary to administer this subsection.
233     (f)  The agency shall seek federal waivers and amend
234contracts as necessary to make changes to services defined in
235federal waiver programs administered by the agency as follows:
236     1.  Supported living coaching services may not exceed 20
237hours per month for persons who also receive in-home support
239     2.  Limited support coordination services is the only type
240of support coordination service that may be provided to persons
241under the age of 18 who live in the family home.
242     3.  Personal care assistance services are limited to 180
243hours per calendar month and may not include rate modifiers.
244Additional hours may be authorized for persons who have
245intensive physical, medical, or adaptive needs if such hours are
246essential for avoiding institutionalization.
247     4.  Residential habilitation services are limited to 8
248hours per day. Additional hours may be authorized for persons
249who have intensive medical or adaptive needs and if such hours
250are essential for avoiding institutionalization, or for persons
251who possess behavioral problems that are exceptional in
252intensity, duration, or frequency and present a substantial risk
253of harming themselves or others. This restriction shall be in
254effect until the four-tiered waiver system is fully implemented.
255     5.  Chore services, nonresidential support services, and
256homemaker services are eliminated. The agency shall expand the
257definition of in-home support services to allow the service
258provider to include activities previously provided in these
259eliminated services.
260     6.  Massage therapy, medication review, and psychological
261assessment services are eliminated.
262     7.  The agency shall conduct supplemental cost plan reviews
263to verify the medical necessity of authorized services for plans
264that have increased by more than 8 percent during either of the
2652 preceding fiscal years.
266     8.  The agency shall implement a consolidated residential
267habilitation rate structure to increase savings to the state
268through a more cost-effective payment method and establish
269uniform rates for intensive behavioral residential habilitation
271     9.  Pending federal approval, the agency may extend current
272support plans for clients receiving services under Medicaid
273waivers for 1 year beginning July 1, 2007, or from the date
274approved, whichever is later. Clients who have a substantial
275change in circumstances which threatens their health and safety
276may be reassessed during this year in order to determine the
277necessity for a change in their support plan.
278     10.  The agency shall develop a plan to eliminate
279redundancies and duplications between in-home support services,
280companion services, personal care services, and supported living
281coaching by limiting or consolidating such services.
282     11.  The agency shall develop a plan to reduce the
283intensity and frequency of supported employment services to
284clients in stable employment situations who have a documented
285history of at least 3 years' employment with the same company or
286in the same industry.
287     (4)  The geographic differential for Miami-Dade, Broward,
288and Palm Beach Counties for residential habilitation services
289shall be 7.5 percent.
290     (5)  The geographic differential for Monroe County for
291residential habilitation services shall be 20 percent.
292     (6)  Effective January 1, 2010, and except as otherwise
293provided in this section, a client served by the home and
294community-based services waiver or the family and supported
295living waiver funded through the agency shall have his or her
296cost plan adjusted to reflect the amount of expenditures for the
297previous state fiscal year plus 5 percent if such amount is less
298than the client's existing cost plan. The agency shall use
299actual paid claims for services provided during the previous
300fiscal year that are submitted by October 31 to calculate the
301revised cost plan amount. If the client was not served for the
302entire previous state fiscal year or there was any single change
303in the cost plan amount of more than 5 percent during the
304previous state fiscal year, the agency shall set the cost plan
305amount at an estimated annualized expenditure amount plus 5
306percent. The agency shall estimate the annualized expenditure
307amount by calculating the average of monthly expenditures,
308beginning in the fourth month after the client enrolled,
309interrupted services are resumed, or the cost plan was changed
310by more than 5 percent and ending on August 31, 2009, and
311multiplying the average by 12. In order to determine whether a
312client was not served for the entire year, the agency shall
313include any interruption of a waiver-funded service or services
314lasting at least 18 days. If at least 3 months of actual
315expenditure data are not available to estimate annualized
316expenditures, the agency may not rebase a cost plan pursuant to
317this subsection. The agency may not rebase the cost plan of any
318client who experiences a significant change in recipient
319condition or circumstance which results in a change of more than
3205 percent to his or her cost plan between July 1 and the date
321that a rebased cost plan would take effect pursuant to this
323     (7)  Nothing in this section or in any administrative rule
324shall be construed to prevent or limit the Agency for Health
325Care Administration, in consultation with the Agency for Persons
326with Disabilities, from adjusting fees, reimbursement rates,
327lengths of stay, number of visits, or number of services, or
328from limiting enrollment, or making any other adjustment
329necessary to comply with the availability of moneys and any
330limitations or directions provided for in the General
331Appropriations Act.
332     (8)  The Agency for Persons with Disabilities shall submit
333quarterly status reports to the Executive Office of the
334Governor, the chair of the Senate Ways and Means Committee or
335its successor, and the chair of the House Fiscal Council or its
336successor regarding the financial status of home and community-
337based services, including the number of enrolled individuals who
338are receiving services through one or more programs; the number
339of individuals who have requested services who are not enrolled
340but who are receiving services through one or more programs,
341with a description indicating the programs from which the
342individual is receiving services; the number of individuals who
343have refused an offer of services but who choose to remain on
344the list of individuals waiting for services; the number of
345individuals who have requested services but who are receiving no
346services; a frequency distribution indicating the length of time
347individuals have been waiting for services; and information
348concerning the actual and projected costs compared to the amount
349of the appropriation available to the program and any projected
350surpluses or deficits. If at any time an analysis by the agency,
351in consultation with the Agency for Health Care Administration,
352indicates that the cost of services is expected to exceed the
353amount appropriated, the agency shall submit a plan in
354accordance with subsection (7) to the Executive Office of the
355Governor, the chair of the Senate Ways and Means Committee or
356its successor, and the chair of the House Fiscal Council or its
357successor to remain within the amount appropriated. The agency
358shall work with the Agency for Health Care Administration to
359implement the plan so as to remain within the appropriation.
360     (9)  The agency shall develop a transition plan for
361recipients who are receiving services in one of the four waiver
362tiers at the time eligible managed care plans are available in
363each recipient's region as defined in s. 409.989 to enroll those
364recipients in eligible plans.
365     (10)  This section expires October 1, 2016.
366     Section 2.  Section 393.0662, Florida Statutes, is amended
367to read:
368     393.0662  Individual budgets for delivery of home and
369community-based services; iBudget system established.-The
370Legislature finds that improved financial management of the
371existing home and community-based Medicaid waiver program is
372necessary to avoid deficits that impede the provision of
373services to individuals who are on the waiting list for
374enrollment in the program. The Legislature further finds that
375clients and their families should have greater flexibility to
376choose the services that best allow them to live in their
377community within the limits of an established budget. Therefore,
378the Legislature intends that the agency, in consultation with
379the Agency for Health Care Administration, develop and implement
380a comprehensive redesign of the service delivery system using
381individual budgets as the basis for allocating the funds
382appropriated for the home and community-based services Medicaid
383waiver program among eligible enrolled clients. The service
384delivery system that uses individual budgets shall be called the
385iBudget system.
386     (1)  The agency shall establish an individual budget,
387referred to as an iBudget, for each individual served by the
388home and community-based services Medicaid waiver program. The
389funds appropriated to the agency shall be allocated through the
390iBudget system to eligible, Medicaid-enrolled clients. The
391iBudget system shall be designed to provide for: enhanced client
392choice within a specified service package; appropriate
393assessment strategies; an efficient consumer budgeting and
394billing process that includes reconciliation and monitoring
395components; a redefined role for support coordinators that
396avoids potential conflicts of interest; a flexible and
397streamlined service review process; and a methodology and
398process that ensures the equitable allocation of available funds
399to each client based on the client's level of need, as
400determined by the variables in the allocation algorithm.
401     (a)  In developing each client's iBudget, the agency shall
402use an allocation algorithm and methodology. The algorithm shall
403use variables that have been determined by the agency to have a
404statistically validated relationship to the client's level of
405need for services provided through the home and community-based
406services Medicaid waiver program. The algorithm and methodology
407may consider individual characteristics, including, but not
408limited to, a client's age and living situation, information
409from a formal assessment instrument that the agency determines
410is valid and reliable, and information from other assessment
412     (b)  The allocation methodology shall provide the algorithm
413that determines the amount of funds allocated to a client's
414iBudget. The agency may approve an increase in the amount of
415funds allocated, as determined by the algorithm, based on the
416client having one or more of the following needs that cannot be
417accommodated within the funding as determined by the algorithm
418and having no other resources, supports, or services available
419to meet the need:
420     1.  An extraordinary need that would place the health and
421safety of the client, the client's caregiver, or the public in
422immediate, serious jeopardy unless the increase is approved. An
423extraordinary need may include, but is not limited to:
424     a.  A documented history of significant, potentially life-
425threatening behaviors, such as recent attempts at suicide,
426arson, nonconsensual sexual behavior, or self-injurious behavior
427requiring medical attention;
428     b.  A complex medical condition that requires active
429intervention by a licensed nurse on an ongoing basis that cannot
430be taught or delegated to a nonlicensed person;
431     c.  A chronic comorbid condition. As used in this
432subparagraph, the term "comorbid condition" means a medical
433condition existing simultaneously but independently with another
434medical condition in a patient; or
435     d.  A need for total physical assistance with activities
436such as eating, bathing, toileting, grooming, and personal
439However, the presence of an extraordinary need alone does not
440warrant an increase in the amount of funds allocated to a
441client's iBudget as determined by the algorithm.
442     2.  A significant need for one-time or temporary support or
443services that, if not provided, would place the health and
444safety of the client, the client's caregiver, or the public in
445serious jeopardy, unless the increase is approved. A significant
446need may include, but is not limited to, the provision of
447environmental modifications, durable medical equipment, services
448to address the temporary loss of support from a caregiver, or
449special services or treatment for a serious temporary condition
450when the service or treatment is expected to ameliorate the
451underlying condition. As used in this subparagraph, the term
452"temporary" means a period of fewer than 12 continuous months.
453However, the presence of such significant need for one-time or
454temporary supports or services alone does not warrant an
455increase in the amount of funds allocated to a client's iBudget
456as determined by the algorithm.
457     3.  A significant increase in the need for services after
458the beginning of the service plan year that would place the
459health and safety of the client, the client's caregiver, or the
460public in serious jeopardy because of substantial changes in the
461client's circumstances, including, but not limited to, permanent
462or long-term loss or incapacity of a caregiver, loss of services
463authorized under the state Medicaid plan due to a change in age,
464or a significant change in medical or functional status which
465requires the provision of additional services on a permanent or
466long-term basis that cannot be accommodated within the client's
467current iBudget. As used in this subparagraph, the term "long-
468term" means a period of 12 or more continuous months. However,
469such significant increase in need for services of a permanent or
470long-term nature alone does not warrant an increase in the
471amount of funds allocated to a client's iBudget as determined by
472the algorithm.
474The agency shall reserve portions of the appropriation for the
475home and community-based services Medicaid waiver program for
476adjustments required pursuant to this paragraph and may use the
477services of an independent actuary in determining the amount of
478the portions to be reserved.
479     (c)  A client's iBudget shall be the total of the amount
480determined by the algorithm and any additional funding provided
481pursuant to paragraph (b). A client's annual expenditures for
482home and community-based services Medicaid waiver services may
483not exceed the limits of his or her iBudget. The total of all
484clients' projected annual iBudget expenditures may not exceed
485the agency's appropriation for waiver services.
486     (2)  The Agency for Health Care Administration, in
487consultation with the agency, shall seek federal approval to
488amend current waivers, request a new waiver, and amend contracts
489as necessary to implement the iBudget system to serve eligible,
490enrolled clients through the home and community-based services
491Medicaid waiver program and the Consumer-Directed Care Plus
493     (3)  The agency shall transition all eligible, enrolled
494clients to the iBudget system. The agency may gradually phase in
495the iBudget system and must complete the phase in by January 1,
497     (a)  While the agency phases in the iBudget system, the
498agency may continue to serve eligible, enrolled clients under
499the four-tiered waiver system established under s. 393.065 while
500those clients await transitioning to the iBudget system.
501     (b)  The agency shall design the phase-in process to ensure
502that a client does not experience more than one-half of any
503expected overall increase or decrease to his or her existing
504annualized cost plan during the first year that the client is
505provided an iBudget due solely to the transition to the iBudget
507     (4)  A client must use all available services authorized
508under the state Medicaid plan, school-based services, private
509insurance and other benefits, and any other resources that may
510be available to the client before using funds from his or her
511iBudget to pay for support and services.
512     (5)  The service limitations in s. 393.0661(3)(f)1., 2.,
513and 3. do not apply to the iBudget system.
514     (6)  Rates for any or all services established under rules
515of the Agency for Health Care Administration shall be designated
516as the maximum rather than a fixed amount for individuals who
517receive an iBudget, except for services specifically identified
518in those rules that the agency determines are not appropriate
519for negotiation, which may include, but are not limited to,
520residential habilitation services.
521     (7)  The agency shall ensure that clients and caregivers
522have access to training and education to inform them about the
523iBudget system and enhance their ability for self-direction.
524Such training shall be offered in a variety of formats and at a
525minimum shall address the policies and processes of the iBudget
526system; the roles and responsibilities of consumers, caregivers,
527waiver support coordinators, providers, and the agency;
528information available to help the client make decisions
529regarding the iBudget system; and examples of support and
530resources available in the community.
531     (8)  The agency shall collect data to evaluate the
532implementation and outcomes of the iBudget system.
533     (9)  The agency and the Agency for Health Care
534Administration may adopt rules specifying the allocation
535algorithm and methodology; criteria and processes for clients to
536access reserved funds for extraordinary needs, temporarily or
537permanently changed needs, and one-time needs; and processes and
538requirements for selection and review of services, development
539of support and cost plans, and management of the iBudget system
540as needed to administer this section.
541     (10)  The agency shall develop a transition plan for
542recipients who are receiving services through the iBudget system
543at the time eligible managed care plans are available in each
544recipient's region defined in s. 409.989 to enroll those
545recipients in eligible plans.
546     (11)  This section expires October 1, 2016.
547     Section 3.  Paragraph (e) of subsection (1) of section
548408.040, Florida Statutes, is redesignated as paragraph (d), and
549paragraph (b) and present paragraph (d) of that subsection are
550amended to read:
551     408.040  Conditions and monitoring.-
552     (1)
553     (b)  The agency may consider, in addition to the other
554criteria specified in s. 408.035, a statement of intent by the
555applicant that a specified percentage of the annual patient days
556at the facility will be utilized by patients eligible for care
557under Title XIX of the Social Security Act. Any certificate of
558need issued to a nursing home in reliance upon an applicant's
559statements that a specified percentage of annual patient days
560will be utilized by residents eligible for care under Title XIX
561of the Social Security Act must include a statement that such
562certification is a condition of issuance of the certificate of
563need. The certificate-of-need program shall notify the Medicaid
564program office and the Department of Elderly Affairs when it
565imposes conditions as authorized in this paragraph in an area in
566which a community diversion pilot project is implemented.
567Effective July 1, 2012, the agency may not consider, or impose
568conditions or sanctions related to, patient day utilization by
569patients eligible for care under Title XIX the Social Security
570Act in making certificate-of-need determinations for nursing
572     (d)  If a nursing home is located in a county in which a
573long-term care community diversion pilot project has been
574implemented under s. 430.705 or in a county in which an
575integrated, fixed-payment delivery program for Medicaid
576recipients who are 60 years of age or older or dually eligible
577for Medicare and Medicaid has been implemented under s.
578409.912(5), the nursing home may request a reduction in the
579percentage of annual patient days used by residents who are
580eligible for care under Title XIX of the Social Security Act,
581which is a condition of the nursing home's certificate of need.
582The agency shall automatically grant the nursing home's request
583if the reduction is not more than 15 percent of the nursing
584home's annual Medicaid-patient-days condition. A nursing home
585may submit only one request every 2 years for an automatic
586reduction. A requesting nursing home must notify the agency in
587writing at least 60 days in advance of its intent to reduce its
588annual Medicaid-patient-days condition by not more than 15
589percent. The agency must acknowledge the request in writing and
590must change its records to reflect the revised certificate-of-
591need condition. This paragraph expires June 30, 2011.
592     Section 4.  Subsection (1) of section 408.0435, Florida
593Statutes, is amended to read:
594     408.0435  Moratorium on nursing home certificates of need.-
595     (1)  Notwithstanding the establishment of need as provided
596for in this chapter, a certificate of need for additional
597community nursing home beds may not be approved by the agency
598until Medicaid managed care is implemented statewide pursuant to
599ss. 409.961-409.992 or October 1, 2016, whichever is earlier
600July 1, 2011.
601     Section 5.  Sections 409.016 through 409.803, Florida
602Statutes, are designated as part I of chapter 409, Florida
603Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
604     Section 6.  Sections 409.810 through 409.821, Florida
605Statutes, are designated as part II of chapter 409, Florida
606Statutes, and entitled "KIDCARE."
607     Section 7.  Sections 409.901 through 409.9205, Florida
608Statutes, are designated as part III of chapter 409, Florida
609Statutes, and entitled "MEDICAID."
610     Section 8.  Paragraph (c) of subsection (5) of section
611409.905, Florida Statutes, is amended, and paragraph (g) is
612added that subsection, to read:
613     409.905  Mandatory Medicaid services.-The agency may make
614payments for the following services, which are required of the
615state by Title XIX of the Social Security Act, furnished by
616Medicaid providers to recipients who are determined to be
617eligible on the dates on which the services were provided. Any
618service under this section shall be provided only when medically
619necessary and in accordance with state and federal law.
620Mandatory services rendered by providers in mobile units to
621Medicaid recipients may be restricted by the agency. Nothing in
622this section shall be construed to prevent or limit the agency
623from adjusting fees, reimbursement rates, lengths of stay,
624number of visits, number of services, or any other adjustments
625necessary to comply with the availability of moneys and any
626limitations or directions provided for in the General
627Appropriations Act or chapter 216.
628     (5)  HOSPITAL INPATIENT SERVICES.-The agency shall pay for
629all covered services provided for the medical care and treatment
630of a recipient who is admitted as an inpatient by a licensed
631physician or dentist to a hospital licensed under part I of
632chapter 395. However, the agency shall limit the payment for
633inpatient hospital services for a Medicaid recipient 21 years of
634age or older to 45 days or the number of days necessary to
635comply with the General Appropriations Act.
636     (c)  The agency shall implement a methodology for
637establishing base reimbursement rates for each hospital based on
638allowable costs, as defined by the agency. Rates shall be
639calculated annually and take effect July 1 of each year based on
640the most recent complete and accurate cost report submitted by
641each hospital. Adjustments may not be made to the rates after
642September 30 of the state fiscal year in which the rate takes
643effect. Errors in cost reporting or calculation of rates
644discovered after September 30 must be reconciled in a subsequent
645rate period. Cost reports must be reconciled within 5 years
646after the end of the applicable fiscal year. Hospital rates
647shall be subject to such limits or ceilings as may be
648established in law or described in the agency's hospital
649reimbursement plan. Specific exemptions to the limits or
650ceilings may be provided in the General Appropriations Act. The
651agency shall adjust a hospital's current inpatient per diem rate
652to reflect the cost of serving the Medicaid population at that
653institution if:
654     1.  The hospital experiences an increase in Medicaid
655caseload by more than 25 percent in any year, primarily
656resulting from the closure of a hospital in the same service
657area occurring after July 1, 1995;
658     2.  The hospital's Medicaid per diem rate is at least 25
659percent below the Medicaid per patient cost for that year; or
660     3.  The hospital is located in a county that has six or
661fewer general acute care hospitals, began offering obstetrical
662services on or after September 1999, and has submitted a request
663in writing to the agency for a rate adjustment after July 1,
6642000, but before September 30, 2000, in which case such
665hospital's Medicaid inpatient per diem rate shall be adjusted to
666cost, effective July 1, 2002.
668By October 1 of each year, the agency must provide estimated
669costs for any adjustment in a hospital inpatient per diem rate
670to the Executive Office of the Governor, the House of
671Representatives General Appropriations Committee, and the Senate
672Appropriations Committee. Before the agency implements a change
673in a hospital's inpatient per diem rate pursuant to this
674paragraph, the Legislature must have specifically appropriated
675sufficient funds in the General Appropriations Act to support
676the increase in cost as estimated by the agency.
677     (g)  The agency shall develop a plan to convert inpatient
678hospital rates to a prospective payment system that categorizes
679each case into diagnosis-related groups (DRG) and assigns a
680payment weight based on the average resources used to treat
681Medicaid patients in that DRG. To the extent possible, the
682agency shall propose an adaptation of an existing prospective
683payment system, such as the one used by Medicare, and shall
684propose such adjustments as are necessary for the Medicaid
685population and to maintain budget neutrality for inpatient
686hospital expenditures. The agency shall submit the Medicaid DRG
687plan, identifying all steps necessary for the transition and any
688costs associated with plan implementation, to the Governor, the
689President of the Senate, and the Speaker of the House of
690Representatives no later than January 1, 2013.
691     Section 9.  Paragraphs (d) and (e) of subsection (5) of
692section 409.907, Florida Statutes, are amended to read:
693     409.907  Medicaid provider agreements.-The agency may make
694payments for medical assistance and related services rendered to
695Medicaid recipients only to an individual or entity who has a
696provider agreement in effect with the agency, who is performing
697services or supplying goods in accordance with federal, state,
698and local law, and who agrees that no person shall, on the
699grounds of handicap, race, color, or national origin, or for any
700other reason, be subjected to discrimination under any program
701or activity for which the provider receives payment from the
703     (5)  The agency:
704     (d)  May enroll entities as Medicare crossover-only
705providers for payment and claims processing purposes only. The
706provider agreement shall:
707     1.  Require that the provider be able to demonstrate to the
708satisfaction of the agency that the provider is an eligible
709Medicare provider and has a current provider agreement in place
710with the Centers for Medicare and Medicaid Services.
711     2.  Require the provider to notify the agency immediately
712in writing upon being suspended or disenrolled as a Medicare
713provider. If the provider does not provide such notification
714within 5 business days after suspension or disenrollment,
715sanctions may be imposed pursuant to this chapter and the
716provider may be required to return funds paid to the provider
717during the period of time that the provider was suspended or
718disenrolled as a Medicare provider.
719     3.  Require the applicant to submit an attestation, as
720approved by the agency, that the provider meets the requirements
721of Florida Medicaid provider enrollment criteria.
722     4.  Require the applicant to submit fingerprints as
723required by the agency.
724     5.3.  Require that all records pertaining to health care
725services provided to each of the provider's recipients be kept
726for a minimum of 6 years. The agreement shall also require that
727records and any information relating to payments claimed by the
728provider for services under the agreement be delivered to the
729agency or the Office of the Attorney General Medicaid Fraud
730Control Unit when requested. If a provider does not provide such
731records and information when requested, sanctions may be imposed
732pursuant to this chapter.
733     6.4.  Disclose that the agreement is for the purposes of
734paying and processing Medicare crossover claims only.
736This paragraph pertains solely to Medicare crossover-only
737providers. In order to become a standard Medicaid provider, the
738requirements of this section and applicable rules must be met.
739This paragraph does not create an entitlement or obligation of
740the agency to enroll all Medicare providers that may be
741considered a Medicare crossover-only provider in the Medicaid
743     (e)  Providers that are required to post a surety bond as
744part of the Medicaid enrollment process are excluded for
745enrollment under paragraph (d) and must complete a full Medicaid
746application. The agency may establish additional criteria to
747promote program integrity.
748     Section 10.  Subsection (10) of section 409.911, Florida
749Statutes, is amended to read:
750     409.911  Disproportionate share program.-Subject to
751specific allocations established within the General
752Appropriations Act and any limitations established pursuant to
753chapter 216, the agency shall distribute, pursuant to this
754section, moneys to hospitals providing a disproportionate share
755of Medicaid or charity care services by making quarterly
756Medicaid payments as required. Notwithstanding the provisions of
757s. 409.915, counties are exempt from contributing toward the
758cost of this special reimbursement for hospitals serving a
759disproportionate share of low-income patients.
760     (10)  The Agency for Health Care Administration shall
761create a Medicaid Low-Income Pool Council by July 1, 2006. The
762Low-Income Pool Council shall consist of 24 members, including 2
763members appointed by the President of the Senate, 2 members
764appointed by the Speaker of the House of Representatives, 3
765representatives of statutory teaching hospitals, 3
766representatives of public hospitals, 3 representatives of
767nonprofit hospitals, 3 representatives of for-profit hospitals,
7682 representatives of rural hospitals, 2 representatives of units
769of local government which contribute funding, 1 representative
770of family practice teaching hospitals, 1 representative of
771federally qualified health centers, 1 representative from the
772Department of Health, and 1 nonvoting representative of the
773Agency for Health Care Administration who shall serve as chair
774of the council. Except for a full-time employee of a public
775entity, an individual who qualifies as a lobbyist under s.
77611.045 or s. 112.3215 may not serve as a member of the council.
777Of the members appointed by the Senate President, only one shall
778be a physician. Of the members appointed by the Speaker of the
779House of Representatives, only one shall be a physician. The
780physician member appointed by the Senate President and the
781physician member appointed by the Speaker of the House of
782Representatives must be physicians who routinely take calls in a
783trauma center, as defined in s. 395.4001, or a hospital
784emergency department. The council shall:
785     (a)  Make recommendations on the financing of the low-
786income pool and the disproportionate share hospital program and
787the distribution of their funds.
788     (b)  Advise the Agency for Health Care Administration on
789the development of the low-income pool plan required by the
790federal Centers for Medicare and Medicaid Services pursuant to
791the Medicaid reform waiver.
792     (c)  Advise the Agency for Health Care Administration on
793the distribution of hospital funds used to adjust inpatient
794hospital rates, rebase rates, or otherwise exempt hospitals from
795reimbursement limits as financed by intergovernmental transfers.
796     (d)  Submit its findings and recommendations to the
797Governor and the Legislature no later than February 1 of each
800This subsection expires October 1, 2014.
801     Section 11.  Subsection (4) of section 409.91195, Florida
802Statutes, is amended to read:
803     409.91195  Medicaid Pharmaceutical and Therapeutics
804Committee.-There is created a Medicaid Pharmaceutical and
805Therapeutics Committee within the agency for the purpose of
806developing a Medicaid preferred drug list.
807     (4)  Upon recommendation of the committee, the agency shall
808adopt a preferred drug list as described in s. 409.912(37)(39).
809To the extent feasible, the committee shall review all drug
810classes included on the preferred drug list every 12 months, and
811may recommend additions to and deletions from the preferred drug
812list, such that the preferred drug list provides for medically
813appropriate drug therapies for Medicaid patients which achieve
814cost savings contained in the General Appropriations Act.
815     Section 12.  Subsection (1) of section 409.91196, Florida
816Statutes, is amended to read:
817     409.91196  Supplemental rebate agreements; public records
818and public meetings exemption.-
819     (1)  The rebate amount, percent of rebate, manufacturer's
820pricing, and supplemental rebate, and other trade secrets as
821defined in s. 688.002 that the agency has identified for use in
822negotiations, held by the Agency for Health Care Administration
823under s. 409.912(37)(39)(a)7. are confidential and exempt from
824s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
825     Section 13.  Section 409.912, Florida Statutes, is amended
826to read:
827     409.912  Cost-effective purchasing of health care.-The
828agency shall purchase goods and services for Medicaid recipients
829in the most cost-effective manner consistent with the delivery
830of quality medical care. To ensure that medical services are
831effectively utilized, the agency may, in any case, require a
832confirmation or second physician's opinion of the correct
833diagnosis for purposes of authorizing future services under the
834Medicaid program. This section does not restrict access to
835emergency services or poststabilization care services as defined
836in 42 C.F.R. part 438.114. Such confirmation or second opinion
837shall be rendered in a manner approved by the agency. The agency
838shall maximize the use of prepaid per capita and prepaid
839aggregate fixed-sum basis services when appropriate and other
840alternative service delivery and reimbursement methodologies,
841including competitive bidding pursuant to s. 287.057, designed
842to facilitate the cost-effective purchase of a case-managed
843continuum of care. The agency shall also require providers to
844minimize the exposure of recipients to the need for acute
845inpatient, custodial, and other institutional care and the
846inappropriate or unnecessary use of high-cost services. The
847agency shall contract with a vendor to monitor and evaluate the
848clinical practice patterns of providers in order to identify
849trends that are outside the normal practice patterns of a
850provider's professional peers or the national guidelines of a
851provider's professional association. The vendor must be able to
852provide information and counseling to a provider whose practice
853patterns are outside the norms, in consultation with the agency,
854to improve patient care and reduce inappropriate utilization.
855The agency may mandate prior authorization, drug therapy
856management, or disease management participation for certain
857populations of Medicaid beneficiaries, certain drug classes, or
858particular drugs to prevent fraud, abuse, overuse, and possible
859dangerous drug interactions. The Pharmaceutical and Therapeutics
860Committee shall make recommendations to the agency on drugs for
861which prior authorization is required. The agency shall inform
862the Pharmaceutical and Therapeutics Committee of its decisions
863regarding drugs subject to prior authorization. The agency is
864authorized to limit the entities it contracts with or enrolls as
865Medicaid providers by developing a provider network through
866provider credentialing. The agency may competitively bid single-
867source-provider contracts if procurement of goods or services
868results in demonstrated cost savings to the state without
869limiting access to care. The agency may limit its network based
870on the assessment of beneficiary access to care, provider
871availability, provider quality standards, time and distance
872standards for access to care, the cultural competence of the
873provider network, demographic characteristics of Medicaid
874beneficiaries, practice and provider-to-beneficiary standards,
875appointment wait times, beneficiary use of services, provider
876turnover, provider profiling, provider licensure history,
877previous program integrity investigations and findings, peer
878review, provider Medicaid policy and billing compliance records,
879clinical and medical record audits, and other factors. Providers
880are shall not be entitled to enrollment in the Medicaid provider
881network. The agency shall determine instances in which allowing
882Medicaid beneficiaries to purchase durable medical equipment and
883other goods is less expensive to the Medicaid program than long-
884term rental of the equipment or goods. The agency may establish
885rules to facilitate purchases in lieu of long-term rentals in
886order to protect against fraud and abuse in the Medicaid program
887as defined in s. 409.913. The agency may seek federal waivers
888necessary to administer these policies.
889     (1)  The agency shall work with the Department of Children
890and Family Services to ensure access of children and families in
891the child protection system to needed and appropriate mental
892health and substance abuse services. This subsection expires
893October 1, 2014.
894     (2)  The agency may enter into agreements with appropriate
895agents of other state agencies or of any agency of the Federal
896Government and accept such duties in respect to social welfare
897or public aid as may be necessary to implement the provisions of
898Title XIX of the Social Security Act and ss. 409.901-409.920.
899This subsection expires October 1, 2016.
900     (3)  The agency may contract with health maintenance
901organizations certified pursuant to part I of chapter 641 for
902the provision of services to recipients. This subsection expires
903October 1, 2014.
904     (4)  The agency may contract with:
905     (a)  An entity that provides no prepaid health care
906services other than Medicaid services under contract with the
907agency and which is owned and operated by a county, county
908health department, or county-owned and operated hospital to
909provide health care services on a prepaid or fixed-sum basis to
910recipients, which entity may provide such prepaid services
911either directly or through arrangements with other providers.
912Such prepaid health care services entities must be licensed
913under parts I and III of chapter 641. An entity recognized under
914this paragraph which demonstrates to the satisfaction of the
915Office of Insurance Regulation of the Financial Services
916Commission that it is backed by the full faith and credit of the
917county in which it is located may be exempted from s. 641.225.
918This paragraph expires October 1, 2014.
919     (b)  An entity that is providing comprehensive behavioral
920health care services to certain Medicaid recipients through a
921capitated, prepaid arrangement pursuant to the federal waiver
922provided for by s. 409.905(5). Such entity must be licensed
923under chapter 624, chapter 636, or chapter 641, or authorized
924under paragraph (c) or paragraph (d), and must possess the
925clinical systems and operational competence to manage risk and
926provide comprehensive behavioral health care to Medicaid
927recipients. As used in this paragraph, the term "comprehensive
928behavioral health care services" means covered mental health and
929substance abuse treatment services that are available to
930Medicaid recipients. The secretary of the Department of Children
931and Family Services shall approve provisions of procurements
932related to children in the department's care or custody before
933enrolling such children in a prepaid behavioral health plan. Any
934contract awarded under this paragraph must be competitively
935procured. In developing the behavioral health care prepaid plan
936procurement document, the agency shall ensure that the
937procurement document requires the contractor to develop and
938implement a plan to ensure compliance with s. 394.4574 related
939to services provided to residents of licensed assisted living
940facilities that hold a limited mental health license. Except as
941provided in subparagraph 5. 8., and except in counties where the
942Medicaid managed care pilot program is authorized pursuant to s.
943409.91211, the agency shall seek federal approval to contract
944with a single entity meeting these requirements to provide
945comprehensive behavioral health care services to all Medicaid
946recipients not enrolled in a Medicaid managed care plan
947authorized under s. 409.91211, a provider service network
948authorized under paragraph (d), or a Medicaid health maintenance
949organization in an AHCA area. In an AHCA area where the Medicaid
950managed care pilot program is authorized pursuant to s.
951409.91211 in one or more counties, the agency may procure a
952contract with a single entity to serve the remaining counties as
953an AHCA area or the remaining counties may be included with an
954adjacent AHCA area and are subject to this paragraph. Each
955entity must offer a sufficient choice of providers in its
956network to ensure recipient access to care and the opportunity
957to select a provider with whom they are satisfied. The network
958shall include all public mental health hospitals. To ensure
959unimpaired access to behavioral health care services by Medicaid
960recipients, all contracts issued pursuant to this paragraph must
961require 80 percent of the capitation paid to the managed care
962plan, including health maintenance organizations and capitated
963provider service networks, to be expended for the provision of
964behavioral health care services. If the managed care plan
965expends less than 80 percent of the capitation paid for the
966provision of behavioral health care services, the difference
967shall be returned to the agency. The agency shall provide the
968plan with a certification letter indicating the amount of
969capitation paid during each calendar year for behavioral health
970care services pursuant to this section. The agency may reimburse
971for substance abuse treatment services on a fee-for-service
972basis until the agency finds that adequate funds are available
973for capitated, prepaid arrangements.
974     1.  By January 1, 2001, The agency shall modify the
975contracts with the entities providing comprehensive inpatient
976and outpatient mental health care services to Medicaid
977recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
978Counties, to include substance abuse treatment services.
979     2.  By July 1, 2003, the agency and the Department of
980Children and Family Services shall execute a written agreement
981that requires collaboration and joint development of all policy,
982budgets, procurement documents, contracts, and monitoring plans
983that have an impact on the state and Medicaid community mental
984health and targeted case management programs.
985     2.3.  Except as provided in subparagraph 5. 8., by July 1,
9862006, the agency and the Department of Children and Family
987Services shall contract with managed care entities in each AHCA
988area except area 6 or arrange to provide comprehensive inpatient
989and outpatient mental health and substance abuse services
990through capitated prepaid arrangements to all Medicaid
991recipients who are eligible to participate in such plans under
992federal law and regulation. In AHCA areas where eligible
993individuals number less than 150,000, the agency shall contract
994with a single managed care plan to provide comprehensive
995behavioral health services to all recipients who are not
996enrolled in a Medicaid health maintenance organization, a
997provider service network authorized under paragraph (d), or a
998Medicaid capitated managed care plan authorized under s.
999409.91211. The agency may contract with more than one
1000comprehensive behavioral health provider to provide care to
1001recipients who are not enrolled in a Medicaid capitated managed
1002care plan authorized under s. 409.91211, a provider service
1003network authorized under paragraph (d), or a Medicaid health
1004maintenance organization in AHCA areas where the eligible
1005population exceeds 150,000. In an AHCA area where the Medicaid
1006managed care pilot program is authorized pursuant to s.
1007409.91211 in one or more counties, the agency may procure a
1008contract with a single entity to serve the remaining counties as
1009an AHCA area or the remaining counties may be included with an
1010adjacent AHCA area and shall be subject to this paragraph.
1011Contracts for comprehensive behavioral health providers awarded
1012pursuant to this section shall be competitively procured. Both
1013for-profit and not-for-profit corporations are eligible to
1014compete. Managed care plans contracting with the agency under
1015subsection (3) or paragraph (d), shall provide and receive
1016payment for the same comprehensive behavioral health benefits as
1017provided in AHCA rules, including handbooks incorporated by
1018reference. In AHCA area 11, the agency shall contract with at
1019least two comprehensive behavioral health care providers to
1020provide behavioral health care to recipients in that area who
1021are enrolled in, or assigned to, the MediPass program. One of
1022the behavioral health care contracts must be with the existing
1023provider service network pilot project, as described in
1024paragraph (d), for the purpose of demonstrating the cost-
1025effectiveness of the provision of quality mental health services
1026through a public hospital-operated managed care model. Payment
1027shall be at an agreed-upon capitated rate to ensure cost
1028savings. Of the recipients in area 11 who are assigned to
1029MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1030MediPass-enrolled recipients shall be assigned to the existing
1031provider service network in area 11 for their behavioral care.
1032     4.  By October 1, 2003, the agency and the department shall
1033submit a plan to the Governor, the President of the Senate, and
1034the Speaker of the House of Representatives which provides for
1035the full implementation of capitated prepaid behavioral health
1036care in all areas of the state.
1037     a.  Implementation shall begin in 2003 in those AHCA areas
1038of the state where the agency is able to establish sufficient
1039capitation rates.
1040     b.  If the agency determines that the proposed capitation
1041rate in any area is insufficient to provide appropriate
1042services, the agency may adjust the capitation rate to ensure
1043that care will be available. The agency and the department may
1044use existing general revenue to address any additional required
1045match but may not over-obligate existing funds on an annualized
1047     c.  Subject to any limitations provided in the General
1048Appropriations Act, the agency, in compliance with appropriate
1049federal authorization, shall develop policies and procedures
1050that allow for certification of local and state funds.
1051     3.5.  Children residing in a statewide inpatient
1052psychiatric program, or in a Department of Juvenile Justice or a
1053Department of Children and Family Services residential program
1054approved as a Medicaid behavioral health overlay services
1055provider may not be included in a behavioral health care prepaid
1056health plan or any other Medicaid managed care plan pursuant to
1057this paragraph.
1058     6.  In converting to a prepaid system of delivery, the
1059agency shall in its procurement document require an entity
1060providing only comprehensive behavioral health care services to
1061prevent the displacement of indigent care patients by enrollees
1062in the Medicaid prepaid health plan providing behavioral health
1063care services from facilities receiving state funding to provide
1064indigent behavioral health care, to facilities licensed under
1065chapter 395 which do not receive state funding for indigent
1066behavioral health care, or reimburse the unsubsidized facility
1067for the cost of behavioral health care provided to the displaced
1068indigent care patient.
1069     4.7.  Traditional community mental health providers under
1070contract with the Department of Children and Family Services
1071pursuant to part IV of chapter 394, child welfare providers
1072under contract with the Department of Children and Family
1073Services in areas 1 and 6, and inpatient mental health providers
1074licensed pursuant to chapter 395 must be offered an opportunity
1075to accept or decline a contract to participate in any provider
1076network for prepaid behavioral health services.
1077     5.8.  All Medicaid-eligible children, except children in
1078area 1 and children in Highlands County, Hardee County, Polk
1079County, or Manatee County of area 6, that are open for child
1080welfare services in the HomeSafeNet system, shall receive their
1081behavioral health care services through a specialty prepaid plan
1082operated by community-based lead agencies through a single
1083agency or formal agreements among several agencies. The
1084specialty prepaid plan must result in savings to the state
1085comparable to savings achieved in other Medicaid managed care
1086and prepaid programs. Such plan must provide mechanisms to
1087maximize state and local revenues. The specialty prepaid plan
1088shall be developed by the agency and the Department of Children
1089and Family Services. The agency may seek federal waivers to
1090implement this initiative. Medicaid-eligible children whose
1091cases are open for child welfare services in the HomeSafeNet
1092system and who reside in AHCA area 10 are exempt from the
1093specialty prepaid plan upon the development of a service
1094delivery mechanism for children who reside in area 10 as
1095specified in s. 409.91211(3)(dd).
1097This paragraph expires October 1, 2014.
1098     (c)  A federally qualified health center or an entity owned
1099by one or more federally qualified health centers or an entity
1100owned by other migrant and community health centers receiving
1101non-Medicaid financial support from the Federal Government to
1102provide health care services on a prepaid or fixed-sum basis to
1103recipients. A federally qualified health center or an entity
1104that is owned by one or more federally qualified health centers
1105and is reimbursed by the agency on a prepaid basis is exempt
1106from parts I and III of chapter 641, but must comply with the
1107solvency requirements in s. 641.2261(2) and meet the appropriate
1108requirements governing financial reserve, quality assurance, and
1109patients' rights established by the agency. This paragraph
1110expires October 1, 2014.
1111     (d)1.  A provider service network may be reimbursed on a
1112fee-for-service or prepaid basis. Prepaid provider service
1113networks shall receive per-member, per-month payments. A
1114provider service network that does not choose to be a prepaid
1115plan shall receive fee-for-service rates with a shared savings
1116settlement. The fee-for-service option shall be available to a
1117provider service network only for the first 5 years of the
1118plan's operation or until the contract year beginning October 1,
11192014, whichever is later. The agency shall annually conduct cost
1120reconciliations to determine the amount of cost savings achieved
1121by fee-for-service provider service networks for the dates of
1122service in the period being reconciled. Only payments for
1123covered services for dates of service within the reconciliation
1124period and paid within 6 months after the last date of service
1125in the reconciliation period shall be included. The agency shall
1126perform the necessary adjustments for the inclusion of claims
1127incurred but not reported within the reconciliation for claims
1128that could be received and paid by the agency after the 6-month
1129claims processing time lag. The agency shall provide the results
1130of the reconciliations to the fee-for-service provider service
1131networks within 45 days after the end of the reconciliation
1132period. The fee-for-service provider service networks shall
1133review and provide written comments or a letter of concurrence
1134to the agency within 45 days after receipt of the reconciliation
1135results. This reconciliation shall be considered final.
1136     2.  A provider service network which is reimbursed by the
1137agency on a prepaid basis shall be exempt from parts I and III
1138of chapter 641, but must comply with the solvency requirements
1139in s. 641.2261(2) and meet appropriate financial reserve,
1140quality assurance, and patient rights requirements as
1141established by the agency.
1142     3.  Medicaid recipients assigned to a provider service
1143network shall be chosen equally from those who would otherwise
1144have been assigned to prepaid plans and MediPass. The agency is
1145authorized to seek federal Medicaid waivers as necessary to
1146implement the provisions of this section. This subparagraph
1147expires October 1, 2014. Any contract previously awarded to a
1148provider service network operated by a hospital pursuant to this
1149subsection shall remain in effect for a period of 3 years
1150following the current contract expiration date, regardless of
1151any contractual provisions to the contrary.
1152     4.  A provider service network is a network established or
1153organized and operated by a health care provider, or group of
1154affiliated health care providers, including minority physician
1155networks and emergency room diversion programs that meet the
1156requirements of s. 409.91211, which provides a substantial
1157proportion of the health care items and services under a
1158contract directly through the provider or affiliated group of
1159providers and may make arrangements with physicians or other
1160health care professionals, health care institutions, or any
1161combination of such individuals or institutions to assume all or
1162part of the financial risk on a prospective basis for the
1163provision of basic health services by the physicians, by other
1164health professionals, or through the institutions. The health
1165care providers must have a controlling interest in the governing
1166body of the provider service network organization.
1167     (e)  An entity that provides only comprehensive behavioral
1168health care services to certain Medicaid recipients through an
1169administrative services organization agreement. Such an entity
1170must possess the clinical systems and operational competence to
1171provide comprehensive health care to Medicaid recipients. As
1172used in this paragraph, the term "comprehensive behavioral
1173health care services" means covered mental health and substance
1174abuse treatment services that are available to Medicaid
1175recipients. Any contract awarded under this paragraph must be
1176competitively procured. The agency must ensure that Medicaid
1177recipients have available the choice of at least two managed
1178care plans for their behavioral health care services. This
1179paragraph expires October 1, 2014.
1180     (f)  An entity that provides in-home physician services to
1181test the cost-effectiveness of enhanced home-based medical care
1182to Medicaid recipients with degenerative neurological diseases
1183and other diseases or disabling conditions associated with high
1184costs to Medicaid. The program shall be designed to serve very
1185disabled persons and to reduce Medicaid reimbursed costs for
1186inpatient, outpatient, and emergency department services. The
1187agency shall contract with vendors on a risk-sharing basis.
1188     (g)  Children's provider networks that provide care
1189coordination and care management for Medicaid-eligible pediatric
1190patients, primary care, authorization of specialty care, and
1191other urgent and emergency care through organized providers
1192designed to service Medicaid eligibles under age 18 and
1193pediatric emergency departments' diversion programs. The
1194networks shall provide after-hour operations, including evening
1195and weekend hours, to promote, when appropriate, the use of the
1196children's networks rather than hospital emergency departments.
1197     (f)(h)  An entity authorized in s. 430.205 to contract with
1198the agency and the Department of Elderly Affairs to provide
1199health care and social services on a prepaid or fixed-sum basis
1200to elderly recipients. Such prepaid health care services
1201entities are exempt from the provisions of part I of chapter 641
1202for the first 3 years of operation. An entity recognized under
1203this paragraph that demonstrates to the satisfaction of the
1204Office of Insurance Regulation that it is backed by the full
1205faith and credit of one or more counties in which it operates
1206may be exempted from s. 641.225. This paragraph expires October
12071, 2013.
1208     (g)(i)  A Children's Medical Services Network, as defined
1209in s. 391.021. This paragraph expires October 1, 2014.
1210     (5)  The Agency for Health Care Administration, in
1211partnership with the Department of Elderly Affairs, shall create
1212an integrated, fixed-payment delivery program for Medicaid
1213recipients who are 60 years of age or older or dually eligible
1214for Medicare and Medicaid. The Agency for Health Care
1215Administration shall implement the integrated program initially
1216on a pilot basis in two areas of the state. The pilot areas
1217shall be Area 7 and Area 11 of the Agency for Health Care
1218Administration. Enrollment in the pilot areas shall be on a
1219voluntary basis and in accordance with approved federal waivers
1220and this section. The agency and its program contractors and
1221providers shall not enroll any individual in the integrated
1222program because the individual or the person legally responsible
1223for the individual fails to choose to enroll in the integrated
1224program. Enrollment in the integrated program shall be
1225exclusively by affirmative choice of the eligible individual or
1226by the person legally responsible for the individual. The
1227integrated program must transfer all Medicaid services for
1228eligible elderly individuals who choose to participate into an
1229integrated-care management model designed to serve Medicaid
1230recipients in the community. The integrated program must combine
1231all funding for Medicaid services provided to individuals who
1232are 60 years of age or older or dually eligible for Medicare and
1233Medicaid into the integrated program, including funds for
1234Medicaid home and community-based waiver services; all Medicaid
1235services authorized in ss. 409.905 and 409.906, excluding funds
1236for Medicaid nursing home services unless the agency is able to
1237demonstrate how the integration of the funds will improve
1238coordinated care for these services in a less costly manner; and
1239Medicare coinsurance and deductibles for persons dually eligible
1240for Medicaid and Medicare as prescribed in s. 409.908(13).
1241     (a)  Individuals who are 60 years of age or older or dually
1242eligible for Medicare and Medicaid and enrolled in the
1243developmental disabilities waiver program, the family and
1244supported-living waiver program, the project AIDS care waiver
1245program, the traumatic brain injury and spinal cord injury
1246waiver program, the consumer-directed care waiver program, and
1247the program of all-inclusive care for the elderly program, and
1248residents of institutional care facilities for the
1249developmentally disabled, must be excluded from the integrated
1251     (b)  Managed care entities who meet or exceed the agency's
1252minimum standards are eligible to operate the integrated
1253program. Entities eligible to participate include managed care
1254organizations licensed under chapter 641, including entities
1255eligible to participate in the nursing home diversion program,
1256other qualified providers as defined in s. 430.703(7), community
1257care for the elderly lead agencies, and other state-certified
1258community service networks that meet comparable standards as
1259defined by the agency, in consultation with the Department of
1260Elderly Affairs and the Office of Insurance Regulation, to be
1261financially solvent and able to take on financial risk for
1262managed care. Community service networks that are certified
1263pursuant to the comparable standards defined by the agency are
1264not required to be licensed under chapter 641. Managed care
1265entities who operate the integrated program shall be subject to
1266s. 408.7056. Eligible entities shall choose to serve enrollees
1267who are dually eligible for Medicare and Medicaid, enrollees who
1268are 60 years of age or older, or both.
1269     (c)  The agency must ensure that the capitation-rate-
1270setting methodology for the integrated program is actuarially
1271sound and reflects the intent to provide quality care in the
1272least restrictive setting. The agency must also require
1273integrated-program providers to develop a credentialing system
1274for service providers and to contract with all Gold Seal nursing
1275homes, where feasible, and exclude, where feasible, chronically
1276poor-performing facilities and providers as defined by the
1277agency. The integrated program must develop and maintain an
1278informal provider grievance system that addresses provider
1279payment and contract problems. The agency shall also establish a
1280formal grievance system to address those issues that were not
1281resolved through the informal grievance system. The integrated
1282program must provide that if the recipient resides in a
1283noncontracted residential facility licensed under chapter 400 or
1284chapter 429 at the time of enrollment in the integrated program,
1285the recipient must be permitted to continue to reside in the
1286noncontracted facility as long as the recipient desires. The
1287integrated program must also provide that, in the absence of a
1288contract between the integrated-program provider and the
1289residential facility licensed under chapter 400 or chapter 429,
1290current Medicaid rates must prevail. The integrated-program
1291provider must ensure that electronic nursing home claims that
1292contain sufficient information for processing are paid within 10
1293business days after receipt. Alternately, the integrated-program
1294provider may establish a capitated payment mechanism to
1295prospectively pay nursing homes at the beginning of each month.
1296The agency and the Department of Elderly Affairs must jointly
1297develop procedures to manage the services provided through the
1298integrated program in order to ensure quality and recipient
1300     (d)  The Office of Program Policy Analysis and Government
1301Accountability, in consultation with the Auditor General, shall
1302comprehensively evaluate the pilot project for the integrated,
1303fixed-payment delivery program for Medicaid recipients created
1304under this subsection. The evaluation shall begin as soon as
1305Medicaid recipients are enrolled in the managed care pilot
1306program plans and shall continue for 24 months thereafter. The
1307evaluation must include assessments of each managed care plan in
1308the integrated program with regard to cost savings; consumer
1309education, choice, and access to services; coordination of care;
1310and quality of care. The evaluation must describe administrative
1311or legal barriers to the implementation and operation of the
1312pilot program and include recommendations regarding statewide
1313expansion of the pilot program. The office shall submit its
1314evaluation report to the Governor, the President of the Senate,
1315and the Speaker of the House of Representatives no later than
1316December 31, 2009.
1317     (e)  The agency may seek federal waivers or Medicaid state
1318plan amendments and adopt rules as necessary to administer the
1319integrated program. The agency may implement the approved
1320federal waivers and other provisions as specified in this
1322     (f)  The implementation of the integrated, fixed-payment
1323delivery program created under this subsection is subject to an
1324appropriation in the General Appropriations Act.
1325     (5)(6)  The agency may contract with any public or private
1326entity otherwise authorized by this section on a prepaid or
1327fixed-sum basis for the provision of health care services to
1328recipients. An entity may provide prepaid services to
1329recipients, either directly or through arrangements with other
1330entities, if each entity involved in providing services:
1331     (a)  Is organized primarily for the purpose of providing
1332health care or other services of the type regularly offered to
1333Medicaid recipients;
1334     (b)  Ensures that services meet the standards set by the
1335agency for quality, appropriateness, and timeliness;
1336     (c)  Makes provisions satisfactory to the agency for
1337insolvency protection and ensures that neither enrolled Medicaid
1338recipients nor the agency will be liable for the debts of the
1340     (d)  Submits to the agency, if a private entity, a
1341financial plan that the agency finds to be fiscally sound and
1342that provides for working capital in the form of cash or
1343equivalent liquid assets excluding revenues from Medicaid
1344premium payments equal to at least the first 3 months of
1345operating expenses or $200,000, whichever is greater;
1346     (e)  Furnishes evidence satisfactory to the agency of
1347adequate liability insurance coverage or an adequate plan of
1348self-insurance to respond to claims for injuries arising out of
1349the furnishing of health care;
1350     (f)  Provides, through contract or otherwise, for periodic
1351review of its medical facilities and services, as required by
1352the agency; and
1353     (g)  Provides organizational, operational, financial, and
1354other information required by the agency.
1356This subsection expires October 1, 2014.
1357     (6)(7)  The agency may contract on a prepaid or fixed-sum
1358basis with any health insurer that:
1359     (a)  Pays for health care services provided to enrolled
1360Medicaid recipients in exchange for a premium payment paid by
1361the agency;
1362     (b)  Assumes the underwriting risk; and
1363     (c)  Is organized and licensed under applicable provisions
1364of the Florida Insurance Code and is currently in good standing
1365with the Office of Insurance Regulation.
1367This subsection expires October 1, 2014.
1368     (7)(8)(a)  The agency may contract on a prepaid or fixed-
1369sum basis with an exclusive provider organization to provide
1370health care services to Medicaid recipients provided that the
1371exclusive provider organization meets applicable managed care
1372plan requirements in this section, ss. 409.9122, 409.9123,
1373409.9128, and 627.6472, and other applicable provisions of law.
1374This subsection expires October 1, 2014.
1375     (b)  For a period of no longer than 24 months after the
1376effective date of this paragraph, when a member of an exclusive
1377provider organization that is contracted by the agency to
1378provide health care services to Medicaid recipients in rural
1379areas without a health maintenance organization obtains services
1380from a provider that participates in the Medicaid program in
1381this state, the provider shall be paid in accordance with the
1382appropriate fee schedule for services provided to eligible
1383Medicaid recipients. The agency may seek waiver authority to
1384implement this paragraph.
1385     (8)(9)  The Agency for Health Care Administration may
1386provide cost-effective purchasing of chiropractic services on a
1387fee-for-service basis to Medicaid recipients through
1388arrangements with a statewide chiropractic preferred provider
1389organization incorporated in this state as a not-for-profit
1390corporation. The agency shall ensure that the benefit limits and
1391prior authorization requirements in the current Medicaid program
1392shall apply to the services provided by the chiropractic
1393preferred provider organization. This subsection expires October
13941, 2014.
1395     (9)(10)  The agency shall not contract on a prepaid or
1396fixed-sum basis for Medicaid services with an entity which knows
1397or reasonably should know that any officer, director, agent,
1398managing employee, or owner of stock or beneficial interest in
1399excess of 5 percent common or preferred stock, or the entity
1400itself, has been found guilty of, regardless of adjudication, or
1401entered a plea of nolo contendere, or guilty, to:
1402     (a)  Fraud;
1403     (b)  Violation of federal or state antitrust statutes,
1404including those proscribing price fixing between competitors and
1405the allocation of customers among competitors;
1406     (c)  Commission of a felony involving embezzlement, theft,
1407forgery, income tax evasion, bribery, falsification or
1408destruction of records, making false statements, receiving
1409stolen property, making false claims, or obstruction of justice;
1411     (d)  Any crime in any jurisdiction which directly relates
1412to the provision of health services on a prepaid or fixed-sum
1415This subsection expires October 1, 2014.
1416     (10)(11)  The agency, after notifying the Legislature, may
1417apply for waivers of applicable federal laws and regulations as
1418necessary to implement more appropriate systems of health care
1419for Medicaid recipients and reduce the cost of the Medicaid
1420program to the state and federal governments and shall implement
1421such programs, after legislative approval, within a reasonable
1422period of time after federal approval. These programs must be
1423designed primarily to reduce the need for inpatient care,
1424custodial care and other long-term or institutional care, and
1425other high-cost services. Prior to seeking legislative approval
1426of such a waiver as authorized by this subsection, the agency
1427shall provide notice and an opportunity for public comment.
1428Notice shall be provided to all persons who have made requests
1429of the agency for advance notice and shall be published in the
1430Florida Administrative Weekly not less than 28 days prior to the
1431intended action. This subsection expires October 1, 2016.
1432     (11)(12)  The agency shall establish a postpayment
1433utilization control program designed to identify recipients who
1434may inappropriately overuse or underuse Medicaid services and
1435shall provide methods to correct such misuse. This subsection
1436expires October 1, 2014.
1437     (12)(13)  The agency shall develop and provide coordinated
1438systems of care for Medicaid recipients and may contract with
1439public or private entities to develop and administer such
1440systems of care among public and private health care providers
1441in a given geographic area. This subsection expires October 1,
1443     (13)(14)(a)  The agency shall operate or contract for the
1444operation of utilization management and incentive systems
1445designed to encourage cost-effective use of services and to
1446eliminate services that are medically unnecessary. The agency
1447shall track Medicaid provider prescription and billing patterns
1448and evaluate them against Medicaid medical necessity criteria
1449and coverage and limitation guidelines adopted by rule. Medical
1450necessity determination requires that service be consistent with
1451symptoms or confirmed diagnosis of illness or injury under
1452treatment and not in excess of the patient's needs. The agency
1453shall conduct reviews of provider exceptions to peer group norms
1454and shall, using statistical methodologies, provider profiling,
1455and analysis of billing patterns, detect and investigate
1456abnormal or unusual increases in billing or payment of claims
1457for Medicaid services and medically unnecessary provision of
1458services. Providers that demonstrate a pattern of submitting
1459claims for medically unnecessary services shall be referred to
1460the Medicaid program integrity unit for investigation. In its
1461annual report, required in s. 409.913, the agency shall report
1462on its efforts to control overutilization as described in this
1463subsection paragraph. This subsection expires October 1, 2014.
1464     (b)  The agency shall develop a procedure for determining
1465whether health care providers and service vendors can provide
1466the Medicaid program using a business case that demonstrates
1467whether a particular good or service can offset the cost of
1468providing the good or service in an alternative setting or
1469through other means and therefore should receive a higher
1470reimbursement. The business case must include, but need not be
1471limited to:
1472     1.  A detailed description of the good or service to be
1473provided, a description and analysis of the agency's current
1474performance of the service, and a rationale documenting how
1475providing the service in an alternative setting would be in the
1476best interest of the state, the agency, and its clients.
1477     2.  A cost-benefit analysis documenting the estimated
1478specific direct and indirect costs, savings, performance
1479improvements, risks, and qualitative and quantitative benefits
1480involved in or resulting from providing the service. The cost-
1481benefit analysis must include a detailed plan and timeline
1482identifying all actions that must be implemented to realize
1483expected benefits. The Secretary of Health Care Administration
1484shall verify that all costs, savings, and benefits are valid and
1486     (c)  If the agency determines that the increased
1487reimbursement is cost-effective, the agency shall recommend a
1488change in the reimbursement schedule for that particular good or
1489service. If, within 12 months after implementing any rate change
1490under this procedure, the agency determines that costs were not
1491offset by the increased reimbursement schedule, the agency may
1492revert to the former reimbursement schedule for the particular
1493good or service.
1494     (14)(15)(a)  The agency shall operate the Comprehensive
1495Assessment and Review for Long-Term Care Services (CARES)
1496nursing facility preadmission screening program to ensure that
1497Medicaid payment for nursing facility care is made only for
1498individuals whose conditions require such care and to ensure
1499that long-term care services are provided in the setting most
1500appropriate to the needs of the person and in the most
1501economical manner possible. The CARES program shall also ensure
1502that individuals participating in Medicaid home and community-
1503based waiver programs meet criteria for those programs,
1504consistent with approved federal waivers.
1505     (b)  The agency shall operate the CARES program through an
1506interagency agreement with the Department of Elderly Affairs.
1507The agency, in consultation with the Department of Elderly
1508Affairs, may contract for any function or activity of the CARES
1509program, including any function or activity required by 42
1510C.F.R. part 483.20, relating to preadmission screening and
1511resident review.
1512     (c)  Prior to making payment for nursing facility services
1513for a Medicaid recipient, the agency must verify that the
1514nursing facility preadmission screening program has determined
1515that the individual requires nursing facility care and that the
1516individual cannot be safely served in community-based programs.
1517The nursing facility preadmission screening program shall refer
1518a Medicaid recipient to a community-based program if the
1519individual could be safely served at a lower cost and the
1520recipient chooses to participate in such program. For
1521individuals whose nursing home stay is initially funded by
1522Medicare and Medicare coverage is being terminated for lack of
1523progress towards rehabilitation, CARES staff shall consult with
1524the person making the determination of progress toward
1525rehabilitation to ensure that the recipient is not being
1526inappropriately disqualified from Medicare coverage. If, in
1527their professional judgment, CARES staff believes that a
1528Medicare beneficiary is still making progress toward
1529rehabilitation, they may assist the Medicare beneficiary with an
1530appeal of the disqualification from Medicare coverage. The use
1531of CARES teams to review Medicare denials for coverage under
1532this section is authorized only if it is determined that such
1533reviews qualify for federal matching funds through Medicaid. The
1534agency shall seek or amend federal waivers as necessary to
1535implement this section.
1536     (d)  For the purpose of initiating immediate prescreening
1537and diversion assistance for individuals residing in nursing
1538homes and in order to make families aware of alternative long-
1539term care resources so that they may choose a more cost-
1540effective setting for long-term placement, CARES staff shall
1541conduct an assessment and review of a sample of individuals
1542whose nursing home stay is expected to exceed 20 days,
1543regardless of the initial funding source for the nursing home
1544placement. CARES staff shall provide counseling and referral
1545services to these individuals regarding choosing appropriate
1546long-term care alternatives. This paragraph does not apply to
1547continuing care facilities licensed under chapter 651 or to
1548retirement communities that provide a combination of nursing
1549home, independent living, and other long-term care services.
1550     (e)  By January 15 of each year, the agency shall submit a
1551report to the Legislature describing the operations of the CARES
1552program. The report must describe:
1553     1.  Rate of diversion to community alternative programs;
1554     2.  CARES program staffing needs to achieve additional
1556     3.  Reasons the program is unable to place individuals in
1557less restrictive settings when such individuals desired such
1558services and could have been served in such settings;
1559     4.  Barriers to appropriate placement, including barriers
1560due to policies or operations of other agencies or state-funded
1561programs; and
1562     5.  Statutory changes necessary to ensure that individuals
1563in need of long-term care services receive care in the least
1564restrictive environment.
1565     (f)  The Department of Elderly Affairs shall track
1566individuals over time who are assessed under the CARES program
1567and who are diverted from nursing home placement. By January 15
1568of each year, the department shall submit to the Legislature a
1569longitudinal study of the individuals who are diverted from
1570nursing home placement. The study must include:
1571     1.  The demographic characteristics of the individuals
1572assessed and diverted from nursing home placement, including,
1573but not limited to, age, race, gender, frailty, caregiver
1574status, living arrangements, and geographic location;
1575     2.  A summary of community services provided to individuals
1576for 1 year after assessment and diversion;
1577     3.  A summary of inpatient hospital admissions for
1578individuals who have been diverted; and
1579     4.  A summary of the length of time between diversion and
1580subsequent entry into a nursing home or death.
1582This subsection expires October 1, 2013.
1583     (15)(16)(a)  The agency shall identify health care
1584utilization and price patterns within the Medicaid program which
1585are not cost-effective or medically appropriate and assess the
1586effectiveness of new or alternate methods of providing and
1587monitoring service, and may implement such methods as it
1588considers appropriate. Such methods may include disease
1589management initiatives, an integrated and systematic approach
1590for managing the health care needs of recipients who are at risk
1591of or diagnosed with a specific disease by using best practices,
1592prevention strategies, clinical-practice improvement, clinical
1593interventions and protocols, outcomes research, information
1594technology, and other tools and resources to reduce overall
1595costs and improve measurable outcomes.
1596     (b)  The responsibility of the agency under this subsection
1597shall include the development of capabilities to identify actual
1598and optimal practice patterns; patient and provider educational
1599initiatives; methods for determining patient compliance with
1600prescribed treatments; fraud, waste, and abuse prevention and
1601detection programs; and beneficiary case management programs.
1602     1.  The practice pattern identification program shall
1603evaluate practitioner prescribing patterns based on national and
1604regional practice guidelines, comparing practitioners to their
1605peer groups. The agency and its Drug Utilization Review Board
1606shall consult with the Department of Health and a panel of
1607practicing health care professionals consisting of the
1608following: the Speaker of the House of Representatives and the
1609President of the Senate shall each appoint three physicians
1610licensed under chapter 458 or chapter 459; and the Governor
1611shall appoint two pharmacists licensed under chapter 465 and one
1612dentist licensed under chapter 466 who is an oral surgeon. Terms
1613of the panel members shall expire at the discretion of the
1614appointing official. The advisory panel shall be responsible for
1615evaluating treatment guidelines and recommending ways to
1616incorporate their use in the practice pattern identification
1617program. Practitioners who are prescribing inappropriately or
1618inefficiently, as determined by the agency, may have their
1619prescribing of certain drugs subject to prior authorization or
1620may be terminated from all participation in the Medicaid
1622     2.  The agency shall also develop educational interventions
1623designed to promote the proper use of medications by providers
1624and beneficiaries.
1625     3.  The agency shall implement a pharmacy fraud, waste, and
1626abuse initiative that may include a surety bond or letter of
1627credit requirement for participating pharmacies, enhanced
1628provider auditing practices, the use of additional fraud and
1629abuse software, recipient management programs for beneficiaries
1630inappropriately using their benefits, and other steps that will
1631eliminate provider and recipient fraud, waste, and abuse. The
1632initiative shall address enforcement efforts to reduce the
1633number and use of counterfeit prescriptions.
1634     4.  By September 30, 2002, the agency shall contract with
1635an entity in the state to implement a wireless handheld clinical
1636pharmacology drug information database for practitioners. The
1637initiative shall be designed to enhance the agency's efforts to
1638reduce fraud, abuse, and errors in the prescription drug benefit
1639program and to otherwise further the intent of this paragraph.
1640     5.  By April 1, 2006, the agency shall contract with an
1641entity to design a database of clinical utilization information
1642or electronic medical records for Medicaid providers. This
1643system must be web-based and allow providers to review on a
1644real-time basis the utilization of Medicaid services, including,
1645but not limited to, physician office visits, inpatient and
1646outpatient hospitalizations, laboratory and pathology services,
1647radiological and other imaging services, dental care, and
1648patterns of dispensing prescription drugs in order to coordinate
1649care and identify potential fraud and abuse.
1650     6.  The agency may apply for any federal waivers needed to
1651administer this paragraph.
1653This subsection expires October 1, 2014.
1654     (16)(17)  An entity contracting on a prepaid or fixed-sum
1655basis shall meet the surplus requirements of s. 641.225. If an
1656entity's surplus falls below an amount equal to the surplus
1657requirements of s. 641.225, the agency shall prohibit the entity
1658from engaging in marketing and preenrollment activities, shall
1659cease to process new enrollments, and may not renew the entity's
1660contract until the required balance is achieved. The
1661requirements of this subsection do not apply:
1662     (a)  Where a public entity agrees to fund any deficit
1663incurred by the contracting entity; or
1664     (b)  Where the entity's performance and obligations are
1665guaranteed in writing by a guaranteeing organization which:
1666     1.  Has been in operation for at least 5 years and has
1667assets in excess of $50 million; or
1668     2.  Submits a written guarantee acceptable to the agency
1669which is irrevocable during the term of the contracting entity's
1670contract with the agency and, upon termination of the contract,
1671until the agency receives proof of satisfaction of all
1672outstanding obligations incurred under the contract.
1674This subsection expires October 1, 2014.
1675     (17)(18)(a)  The agency may require an entity contracting
1676on a prepaid or fixed-sum basis to establish a restricted
1677insolvency protection account with a federally guaranteed
1678financial institution licensed to do business in this state. The
1679entity shall deposit into that account 5 percent of the
1680capitation payments made by the agency each month until a
1681maximum total of 2 percent of the total current contract amount
1682is reached. The restricted insolvency protection account may be
1683drawn upon with the authorized signatures of two persons
1684designated by the entity and two representatives of the agency.
1685If the agency finds that the entity is insolvent, the agency may
1686draw upon the account solely with the two authorized signatures
1687of representatives of the agency, and the funds may be disbursed
1688to meet financial obligations incurred by the entity under the
1689prepaid contract. If the contract is terminated, expired, or not
1690continued, the account balance must be released by the agency to
1691the entity upon receipt of proof of satisfaction of all
1692outstanding obligations incurred under this contract.
1693     (b)  The agency may waive the insolvency protection account
1694requirement in writing when evidence is on file with the agency
1695of adequate insolvency insurance and reinsurance that will
1696protect enrollees if the entity becomes unable to meet its
1699This subsection expires October 1, 2014.
1700     (18)(19)  An entity that contracts with the agency on a
1701prepaid or fixed-sum basis for the provision of Medicaid
1702services shall reimburse any hospital or physician that is
1703outside the entity's authorized geographic service area as
1704specified in its contract with the agency, and that provides
1705services authorized by the entity to its members, at a rate
1706negotiated with the hospital or physician for the provision of
1707services or according to the lesser of the following:
1708     (a)  The usual and customary charges made to the general
1709public by the hospital or physician; or
1710     (b)  The Florida Medicaid reimbursement rate established
1711for the hospital or physician.
1713This subsection expires October 1, 2014.
1714     (19)(20)  When a merger or acquisition of a Medicaid
1715prepaid contractor has been approved by the Office of Insurance
1716Regulation pursuant to s. 628.4615, the agency shall approve the
1717assignment or transfer of the appropriate Medicaid prepaid
1718contract upon request of the surviving entity of the merger or
1719acquisition if the contractor and the other entity have been in
1720good standing with the agency for the most recent 12-month
1721period, unless the agency determines that the assignment or
1722transfer would be detrimental to the Medicaid recipients or the
1723Medicaid program. To be in good standing, an entity must not
1724have failed accreditation or committed any material violation of
1725the requirements of s. 641.52 and must meet the Medicaid
1726contract requirements. For purposes of this section, a merger or
1727acquisition means a change in controlling interest of an entity,
1728including an asset or stock purchase. This subsection expires
1729October 1, 2014.
1730     (20)(21)  Any entity contracting with the agency pursuant
1731to this section to provide health care services to Medicaid
1732recipients is prohibited from engaging in any of the following
1733practices or activities:
1734     (a)  Practices that are discriminatory, including, but not
1735limited to, attempts to discourage participation on the basis of
1736actual or perceived health status.
1737     (b)  Activities that could mislead or confuse recipients,
1738or misrepresent the organization, its marketing representatives,
1739or the agency. Violations of this paragraph include, but are not
1740limited to:
1741     1.  False or misleading claims that marketing
1742representatives are employees or representatives of the state or
1743county, or of anyone other than the entity or the organization
1744by whom they are reimbursed.
1745     2.  False or misleading claims that the entity is
1746recommended or endorsed by any state or county agency, or by any
1747other organization which has not certified its endorsement in
1748writing to the entity.
1749     3.  False or misleading claims that the state or county
1750recommends that a Medicaid recipient enroll with an entity.
1751     4.  Claims that a Medicaid recipient will lose benefits
1752under the Medicaid program, or any other health or welfare
1753benefits to which the recipient is legally entitled, if the
1754recipient does not enroll with the entity.
1755     (c)  Granting or offering of any monetary or other valuable
1756consideration for enrollment, except as authorized by subsection
1757(23) (24).
1758     (d)  Door-to-door solicitation of recipients who have not
1759contacted the entity or who have not invited the entity to make
1760a presentation.
1761     (e)  Solicitation of Medicaid recipients by marketing
1762representatives stationed in state offices unless approved and
1763supervised by the agency or its agent and approved by the
1764affected state agency when solicitation occurs in an office of
1765the state agency. The agency shall ensure that marketing
1766representatives stationed in state offices shall market their
1767managed care plans to Medicaid recipients only in designated
1768areas and in such a way as to not interfere with the recipients'
1769activities in the state office.
1770     (f)  Enrollment of Medicaid recipients.
1772This subsection expires October 1, 2014.
1773     (21)(22)  The agency may impose a fine for a violation of
1774this section or the contract with the agency by a person or
1775entity that is under contract with the agency. With respect to
1776any nonwillful violation, such fine shall not exceed $2,500 per
1777violation. In no event shall such fine exceed an aggregate
1778amount of $10,000 for all nonwillful violations arising out of
1779the same action. With respect to any knowing and willful
1780violation of this section or the contract with the agency, the
1781agency may impose a fine upon the entity in an amount not to
1782exceed $20,000 for each such violation. In no event shall such
1783fine exceed an aggregate amount of $100,000 for all knowing and
1784willful violations arising out of the same action. This
1785subsection expires October 1, 2014.
1786     (22)(23)  A health maintenance organization or a person or
1787entity exempt from chapter 641 that is under contract with the
1788agency for the provision of health care services to Medicaid
1789recipients may not use or distribute marketing materials used to
1790solicit Medicaid recipients, unless such materials have been
1791approved by the agency. The provisions of this subsection do not
1792apply to general advertising and marketing materials used by a
1793health maintenance organization to solicit both non-Medicaid
1794subscribers and Medicaid recipients. This subsection expires
1795October 1, 2014.
1796     (23)(24)  Upon approval by the agency, health maintenance
1797organizations and persons or entities exempt from chapter 641
1798that are under contract with the agency for the provision of
1799health care services to Medicaid recipients may be permitted
1800within the capitation rate to provide additional health benefits
1801that the agency has found are of high quality, are practicably
1802available, provide reasonable value to the recipient, and are
1803provided at no additional cost to the state. This subsection
1804expires October 1, 2014.
1805     (24)(25)  The agency shall utilize the statewide health
1806maintenance organization complaint hotline for the purpose of
1807investigating and resolving Medicaid and prepaid health plan
1808complaints, maintaining a record of complaints and confirmed
1809problems, and receiving disenrollment requests made by
1810recipients. This subsection expires October 1, 2014.
1811     (25)(26)  The agency shall require the publication of the
1812health maintenance organization's and the prepaid health plan's
1813consumer services telephone numbers and the "800" telephone
1814number of the statewide health maintenance organization
1815complaint hotline on each Medicaid identification card issued by
1816a health maintenance organization or prepaid health plan
1817contracting with the agency to serve Medicaid recipients and on
1818each subscriber handbook issued to a Medicaid recipient. This
1819subsection expires October 1, 2014.
1820     (26)(27)  The agency shall establish a health care quality
1821improvement system for those entities contracting with the
1822agency pursuant to this section, incorporating all the standards
1823and guidelines developed by the Medicaid Bureau of the Health
1824Care Financing Administration as a part of the quality assurance
1825reform initiative. The system shall include, but need not be
1826limited to, the following:
1827     (a)  Guidelines for internal quality assurance programs,
1828including standards for:
1829     1.  Written quality assurance program descriptions.
1830     2.  Responsibilities of the governing body for monitoring,
1831evaluating, and making improvements to care.
1832     3.  An active quality assurance committee.
1833     4.  Quality assurance program supervision.
1834     5.  Requiring the program to have adequate resources to
1835effectively carry out its specified activities.
1836     6.  Provider participation in the quality assurance
1838     7.  Delegation of quality assurance program activities.
1839     8.  Credentialing and recredentialing.
1840     9.  Enrollee rights and responsibilities.
1841     10.  Availability and accessibility to services and care.
1842     11.  Ambulatory care facilities.
1843     12.  Accessibility and availability of medical records, as
1844well as proper recordkeeping and process for record review.
1845     13.  Utilization review.
1846     14.  A continuity of care system.
1847     15.  Quality assurance program documentation.
1848     16.  Coordination of quality assurance activity with other
1849management activity.
1850     17.  Delivering care to pregnant women and infants; to
1851elderly and disabled recipients, especially those who are at
1852risk of institutional placement; to persons with developmental
1853disabilities; and to adults who have chronic, high-cost medical
1855     (b)  Guidelines which require the entities to conduct
1856quality-of-care studies which:
1857     1.  Target specific conditions and specific health service
1858delivery issues for focused monitoring and evaluation.
1859     2.  Use clinical care standards or practice guidelines to
1860objectively evaluate the care the entity delivers or fails to
1861deliver for the targeted clinical conditions and health services
1862delivery issues.
1863     3.  Use quality indicators derived from the clinical care
1864standards or practice guidelines to screen and monitor care and
1865services delivered.
1866     (c)  Guidelines for external quality review of each
1867contractor which require: focused studies of patterns of care;
1868individual care review in specific situations; and followup
1869activities on previous pattern-of-care study findings and
1870individual-care-review findings. In designing the external
1871quality review function and determining how it is to operate as
1872part of the state's overall quality improvement system, the
1873agency shall construct its external quality review organization
1874and entity contracts to address each of the following:
1875     1.  Delineating the role of the external quality review
1877     2.  Length of the external quality review organization
1878contract with the state.
1879     3.  Participation of the contracting entities in designing
1880external quality review organization review activities.
1881     4.  Potential variation in the type of clinical conditions
1882and health services delivery issues to be studied at each plan.
1883     5.  Determining the number of focused pattern-of-care
1884studies to be conducted for each plan.
1885     6.  Methods for implementing focused studies.
1886     7.  Individual care review.
1887     8.  Followup activities.
1889This subsection expires October 1, 2016.
1890     (27)(28)  In order to ensure that children receive health
1891care services for which an entity has already been compensated,
1892an entity contracting with the agency pursuant to this section
1893shall achieve an annual Early and Periodic Screening, Diagnosis,
1894and Treatment (EPSDT) Service screening rate of at least 60
1895percent for those recipients continuously enrolled for at least
18968 months. The agency shall develop a method by which the EPSDT
1897screening rate shall be calculated. For any entity which does
1898not achieve the annual 60 percent rate, the entity must submit a
1899corrective action plan for the agency's approval. If the entity
1900does not meet the standard established in the corrective action
1901plan during the specified timeframe, the agency is authorized to
1902impose appropriate contract sanctions. At least annually, the
1903agency shall publicly release the EPSDT Services screening rates
1904of each entity it has contracted with on a prepaid basis to
1905serve Medicaid recipients. This subsection expires October 1,
1907     (28)(29)  The agency shall perform enrollments and
1908disenrollments for Medicaid recipients who are eligible for
1909MediPass or managed care plans. Notwithstanding the prohibition
1910contained in paragraph (20)(21)(f), managed care plans may
1911perform preenrollments of Medicaid recipients under the
1912supervision of the agency or its agents. For the purposes of
1913this section, the term "preenrollment" means the provision of
1914marketing and educational materials to a Medicaid recipient and
1915assistance in completing the application forms, but does not
1916include actual enrollment into a managed care plan. An
1917application for enrollment may not be deemed complete until the
1918agency or its agent verifies that the recipient made an
1919informed, voluntary choice. The agency, in cooperation with the
1920Department of Children and Family Services, may test new
1921marketing initiatives to inform Medicaid recipients about their
1922managed care options at selected sites. The agency may contract
1923with a third party to perform managed care plan and MediPass
1924enrollment and disenrollment services for Medicaid recipients
1925and may adopt rules to administer such services. The agency may
1926adjust the capitation rate only to cover the costs of a third-
1927party enrollment and disenrollment contract, and for agency
1928supervision and management of the managed care plan enrollment
1929and disenrollment contract. This subsection expires October 1,
1931     (29)(30)  Any lists of providers made available to Medicaid
1932recipients, MediPass enrollees, or managed care plan enrollees
1933shall be arranged alphabetically showing the provider's name and
1934specialty and, separately, by specialty in alphabetical order.
1935This subsection expires October 1, 2014.
1936     (30)(31)  The agency shall establish an enhanced managed
1937care quality assurance oversight function, to include at least
1938the following components:
1939     (a)  At least quarterly analysis and followup, including
1940sanctions as appropriate, of managed care participant
1941utilization of services.
1942     (b)  At least quarterly analysis and followup, including
1943sanctions as appropriate, of quality findings of the Medicaid
1944peer review organization and other external quality assurance
1946     (c)  At least quarterly analysis and followup, including
1947sanctions as appropriate, of the fiscal viability of managed
1948care plans.
1949     (d)  At least quarterly analysis and followup, including
1950sanctions as appropriate, of managed care participant
1951satisfaction and disenrollment surveys.
1952     (e)  The agency shall conduct regular and ongoing Medicaid
1953recipient satisfaction surveys.
1955The analyses and followup activities conducted by the agency
1956under its enhanced managed care quality assurance oversight
1957function shall not duplicate the activities of accreditation
1958reviewers for entities regulated under part III of chapter 641,
1959but may include a review of the finding of such reviewers. This
1960subsection expires October 1, 2014.
1961     (31)(32)  Each managed care plan that is under contract
1962with the agency to provide health care services to Medicaid
1963recipients shall annually conduct a background check with the
1964Department of Law Enforcement of all persons with ownership
1965interest of 5 percent or more or executive management
1966responsibility for the managed care plan and shall submit to the
1967agency information concerning any such person who has been found
1968guilty of, regardless of adjudication, or has entered a plea of
1969nolo contendere or guilty to, any of the offenses listed in s.
1970435.04. This subsection expires October 1, 2014.
1971     (32)(33)  The agency shall, by rule, develop a process
1972whereby a Medicaid managed care plan enrollee who wishes to
1973enter hospice care may be disenrolled from the managed care plan
1974within 24 hours after contacting the agency regarding such
1975request. The agency rule shall include a methodology for the
1976agency to recoup managed care plan payments on a pro rata basis
1977if payment has been made for the enrollment month when
1978disenrollment occurs. This subsection expires October 1, 2014.
1979     (33)(34)  The agency and entities that contract with the
1980agency to provide health care services to Medicaid recipients
1981under this section or ss. 409.91211 and 409.9122 must comply
1982with the provisions of s. 641.513 in providing emergency
1983services and care to Medicaid recipients and MediPass
1984recipients. Where feasible, safe, and cost-effective, the agency
1985shall encourage hospitals, emergency medical services providers,
1986and other public and private health care providers to work
1987together in their local communities to enter into agreements or
1988arrangements to ensure access to alternatives to emergency
1989services and care for those Medicaid recipients who need
1990nonemergent care. The agency shall coordinate with hospitals,
1991emergency medical services providers, private health plans,
1992capitated managed care networks as established in s. 409.91211,
1993and other public and private health care providers to implement
1994the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1995and 641.31097 to develop and implement emergency department
1996diversion programs for Medicaid recipients. This subsection
1997expires October 1, 2014.
1998     (34)(35)  All entities providing health care services to
1999Medicaid recipients shall make available, and encourage all
2000pregnant women and mothers with infants to receive, and provide
2001documentation in the medical records to reflect, the following:
2002     (a)  Healthy Start prenatal or infant screening.
2003     (b)  Healthy Start care coordination, when screening or
2004other factors indicate need.
2005     (c)  Healthy Start enhanced services in accordance with the
2006prenatal or infant screening results.
2007     (d)  Immunizations in accordance with recommendations of
2008the Advisory Committee on Immunization Practices of the United
2009States Public Health Service and the American Academy of
2010Pediatrics, as appropriate.
2011     (e)  Counseling and services for family planning to all
2012women and their partners.
2013     (f)  A scheduled postpartum visit for the purpose of
2014voluntary family planning, to include discussion of all methods
2015of contraception, as appropriate.
2016     (g)  Referral to the Special Supplemental Nutrition Program
2017for Women, Infants, and Children (WIC).
2019This subsection expires October 1, 2014.
2020     (35)(36)  Any entity that provides Medicaid prepaid health
2021plan services shall ensure the appropriate coordination of
2022health care services with an assisted living facility in cases
2023where a Medicaid recipient is both a member of the entity's
2024prepaid health plan and a resident of the assisted living
2025facility. If the entity is at risk for Medicaid targeted case
2026management and behavioral health services, the entity shall
2027inform the assisted living facility of the procedures to follow
2028should an emergent condition arise. This subsection expires
2029October 1, 2014.
2030     (37)  The agency may seek and implement federal waivers
2031necessary to provide for cost-effective purchasing of home
2032health services, private duty nursing services, transportation,
2033independent laboratory services, and durable medical equipment
2034and supplies through competitive bidding pursuant to s. 287.057.
2035The agency may request appropriate waivers from the federal
2036Health Care Financing Administration in order to competitively
2037bid such services. The agency may exclude providers not selected
2038through the bidding process from the Medicaid provider network.
2039     (36)(38)  The agency shall enter into agreements with not-
2040for-profit organizations based in this state for the purpose of
2041providing vision screening. This subsection expires October 1,
2043     (37)(39)(a)  The agency shall implement a Medicaid
2044prescribed-drug spending-control program that includes the
2045following components:
2046     1.  A Medicaid preferred drug list, which shall be a
2047listing of cost-effective therapeutic options recommended by the
2048Medicaid Pharmacy and Therapeutics Committee established
2049pursuant to s. 409.91195 and adopted by the agency for each
2050therapeutic class on the preferred drug list. At the discretion
2051of the committee, and when feasible, the preferred drug list
2052should include at least two products in a therapeutic class. The
2053agency may post the preferred drug list and updates to the
2054preferred drug list on an Internet website without following the
2055rulemaking procedures of chapter 120. Antiretroviral agents are
2056excluded from the preferred drug list. The agency shall also
2057limit the amount of a prescribed drug dispensed to no more than
2058a 34-day supply unless the drug products' smallest marketed
2059package is greater than a 34-day supply, or the drug is
2060determined by the agency to be a maintenance drug in which case
2061a 100-day maximum supply may be authorized. The agency is
2062authorized to seek any federal waivers necessary to implement
2063these cost-control programs and to continue participation in the
2064federal Medicaid rebate program, or alternatively to negotiate
2065state-only manufacturer rebates. The agency may adopt rules to
2066implement this subparagraph. The agency shall continue to
2067provide unlimited contraceptive drugs and items. The agency must
2068establish procedures to ensure that:
2069     a.  There is a response to a request for prior consultation
2070by telephone or other telecommunication device within 24 hours
2071after receipt of a request for prior consultation; and
2072     b.  A 72-hour supply of the drug prescribed is provided in
2073an emergency or when the agency does not provide a response
2074within 24 hours as required by sub-subparagraph a.
2075     2.  Reimbursement to pharmacies for Medicaid prescribed
2076drugs shall be set at the lesser of: the average wholesale price
2077(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2078plus 4.75 percent, the federal upper limit (FUL), the state
2079maximum allowable cost (SMAC), or the usual and customary (UAC)
2080charge billed by the provider.
2081     3.  The agency shall develop and implement a process for
2082managing the drug therapies of Medicaid recipients who are using
2083significant numbers of prescribed drugs each month. The
2084management process may include, but is not limited to,
2085comprehensive, physician-directed medical-record reviews, claims
2086analyses, and case evaluations to determine the medical
2087necessity and appropriateness of a patient's treatment plan and
2088drug therapies. The agency may contract with a private
2089organization to provide drug-program-management services. The
2090Medicaid drug benefit management program shall include
2091initiatives to manage drug therapies for HIV/AIDS patients,
2092patients using 20 or more unique prescriptions in a 180-day
2093period, and the top 1,000 patients in annual spending. The
2094agency shall enroll any Medicaid recipient in the drug benefit
2095management program if he or she meets the specifications of this
2096provision and is not enrolled in a Medicaid health maintenance
2098     4.  The agency may limit the size of its pharmacy network
2099based on need, competitive bidding, price negotiations,
2100credentialing, or similar criteria. The agency shall give
2101special consideration to rural areas in determining the size and
2102location of pharmacies included in the Medicaid pharmacy
2103network. A pharmacy credentialing process may include criteria
2104such as a pharmacy's full-service status, location, size,
2105patient educational programs, patient consultation, disease
2106management services, and other characteristics. The agency may
2107impose a moratorium on Medicaid pharmacy enrollment when it is
2108determined that it has a sufficient number of Medicaid-
2109participating providers. The agency must allow dispensing
2110practitioners to participate as a part of the Medicaid pharmacy
2111network regardless of the practitioner's proximity to any other
2112entity that is dispensing prescription drugs under the Medicaid
2113program. A dispensing practitioner must meet all credentialing
2114requirements applicable to his or her practice, as determined by
2115the agency.
2116     5.  The agency shall develop and implement a program that
2117requires Medicaid practitioners who prescribe drugs to use a
2118counterfeit-proof prescription pad for Medicaid prescriptions.
2119The agency shall require the use of standardized counterfeit-
2120proof prescription pads by Medicaid-participating prescribers or
2121prescribers who write prescriptions for Medicaid recipients. The
2122agency may implement the program in targeted geographic areas or
2124     6.  The agency may enter into arrangements that require
2125manufacturers of generic drugs prescribed to Medicaid recipients
2126to provide rebates of at least 15.1 percent of the average
2127manufacturer price for the manufacturer's generic products.
2128These arrangements shall require that if a generic-drug
2129manufacturer pays federal rebates for Medicaid-reimbursed drugs
2130at a level below 15.1 percent, the manufacturer must provide a
2131supplemental rebate to the state in an amount necessary to
2132achieve a 15.1-percent rebate level.
2133     7.  The agency may establish a preferred drug list as
2134described in this subsection, and, pursuant to the establishment
2135of such preferred drug list, it is authorized to negotiate
2136supplemental rebates from manufacturers that are in addition to
2137those required by Title XIX of the Social Security Act and at no
2138less than 14 percent of the average manufacturer price as
2139defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2140the federal or supplemental rebate, or both, equals or exceeds
214129 percent. There is no upper limit on the supplemental rebates
2142the agency may negotiate. The agency may determine that specific
2143products, brand-name or generic, are competitive at lower rebate
2144percentages. Agreement to pay the minimum supplemental rebate
2145percentage will guarantee a manufacturer that the Medicaid
2146Pharmaceutical and Therapeutics Committee will consider a
2147product for inclusion on the preferred drug list. However, a
2148pharmaceutical manufacturer is not guaranteed placement on the
2149preferred drug list by simply paying the minimum supplemental
2150rebate. Agency decisions will be made on the clinical efficacy
2151of a drug and recommendations of the Medicaid Pharmaceutical and
2152Therapeutics Committee, as well as the price of competing
2153products minus federal and state rebates. The agency is
2154authorized to contract with an outside agency or contractor to
2155conduct negotiations for supplemental rebates. For the purposes
2156of this section, the term "supplemental rebates" means cash
2157rebates. Effective July 1, 2004, value-added programs as a
2158substitution for supplemental rebates are prohibited. The agency
2159is authorized to seek any federal waivers to implement this
2161     8.  The Agency for Health Care Administration shall expand
2162home delivery of pharmacy products. To assist Medicaid patients
2163in securing their prescriptions and reduce program costs, the
2164agency shall expand its current mail-order-pharmacy diabetes-
2165supply program to include all generic and brand-name drugs used
2166by Medicaid patients with diabetes. Medicaid recipients in the
2167current program may obtain nondiabetes drugs on a voluntary
2168basis. This initiative is limited to the geographic area covered
2169by the current contract. The agency may seek and implement any
2170federal waivers necessary to implement this subparagraph.
2171     9.  The agency shall limit to one dose per month any drug
2172prescribed to treat erectile dysfunction.
2173     10.a.  The agency may implement a Medicaid behavioral drug
2174management system. The agency may contract with a vendor that
2175has experience in operating behavioral drug management systems
2176to implement this program. The agency is authorized to seek
2177federal waivers to implement this program.
2178     b.  The agency, in conjunction with the Department of
2179Children and Family Services, may implement the Medicaid
2180behavioral drug management system that is designed to improve
2181the quality of care and behavioral health prescribing practices
2182based on best practice guidelines, improve patient adherence to
2183medication plans, reduce clinical risk, and lower prescribed
2184drug costs and the rate of inappropriate spending on Medicaid
2185behavioral drugs. The program may include the following
2187     (I)  Provide for the development and adoption of best
2188practice guidelines for behavioral health-related drugs such as
2189antipsychotics, antidepressants, and medications for treating
2190bipolar disorders and other behavioral conditions; translate
2191them into practice; review behavioral health prescribers and
2192compare their prescribing patterns to a number of indicators
2193that are based on national standards; and determine deviations
2194from best practice guidelines.
2195     (II)  Implement processes for providing feedback to and
2196educating prescribers using best practice educational materials
2197and peer-to-peer consultation.
2198     (III)  Assess Medicaid beneficiaries who are outliers in
2199their use of behavioral health drugs with regard to the numbers
2200and types of drugs taken, drug dosages, combination drug
2201therapies, and other indicators of improper use of behavioral
2202health drugs.
2203     (IV)  Alert prescribers to patients who fail to refill
2204prescriptions in a timely fashion, are prescribed multiple same-
2205class behavioral health drugs, and may have other potential
2206medication problems.
2207     (V)  Track spending trends for behavioral health drugs and
2208deviation from best practice guidelines.
2209     (VI)  Use educational and technological approaches to
2210promote best practices, educate consumers, and train prescribers
2211in the use of practice guidelines.
2212     (VII)  Disseminate electronic and published materials.
2213     (VIII)  Hold statewide and regional conferences.
2214     (IX)  Implement a disease management program with a model
2215quality-based medication component for severely mentally ill
2216individuals and emotionally disturbed children who are high
2217users of care.
2218     11.a.  The agency shall implement a Medicaid prescription
2219drug management system. The agency may contract with a vendor
2220that has experience in operating prescription drug management
2221systems in order to implement this system. Any management system
2222that is implemented in accordance with this subparagraph must
2223rely on cooperation between physicians and pharmacists to
2224determine appropriate practice patterns and clinical guidelines
2225to improve the prescribing, dispensing, and use of drugs in the
2226Medicaid program. The agency may seek federal waivers to
2227implement this program.
2228     b.  The drug management system must be designed to improve
2229the quality of care and prescribing practices based on best
2230practice guidelines, improve patient adherence to medication
2231plans, reduce clinical risk, and lower prescribed drug costs and
2232the rate of inappropriate spending on Medicaid prescription
2233drugs. The program must:
2234     (I)  Provide for the development and adoption of best
2235practice guidelines for the prescribing and use of drugs in the
2236Medicaid program, including translating best practice guidelines
2237into practice; reviewing prescriber patterns and comparing them
2238to indicators that are based on national standards and practice
2239patterns of clinical peers in their community, statewide, and
2240nationally; and determine deviations from best practice
2242     (II)  Implement processes for providing feedback to and
2243educating prescribers using best practice educational materials
2244and peer-to-peer consultation.
2245     (III)  Assess Medicaid recipients who are outliers in their
2246use of a single or multiple prescription drugs with regard to
2247the numbers and types of drugs taken, drug dosages, combination
2248drug therapies, and other indicators of improper use of
2249prescription drugs.
2250     (IV)  Alert prescribers to patients who fail to refill
2251prescriptions in a timely fashion, are prescribed multiple drugs
2252that may be redundant or contraindicated, or may have other
2253potential medication problems.
2254     (V)  Track spending trends for prescription drugs and
2255deviation from best practice guidelines.
2256     (VI)  Use educational and technological approaches to
2257promote best practices, educate consumers, and train prescribers
2258in the use of practice guidelines.
2259     (VII)  Disseminate electronic and published materials.
2260     (VIII)  Hold statewide and regional conferences.
2261     (IX)  Implement disease management programs in cooperation
2262with physicians and pharmacists, along with a model quality-
2263based medication component for individuals having chronic
2264medical conditions.
2265     12.  The agency is authorized to contract for drug rebate
2266administration, including, but not limited to, calculating
2267rebate amounts, invoicing manufacturers, negotiating disputes
2268with manufacturers, and maintaining a database of rebate
2270     13.  The agency may specify the preferred daily dosing form
2271or strength for the purpose of promoting best practices with
2272regard to the prescribing of certain drugs as specified in the
2273General Appropriations Act and ensuring cost-effective
2274prescribing practices.
2275     14.  The agency may require prior authorization for
2276Medicaid-covered prescribed drugs. The agency may, but is not
2277required to, prior-authorize the use of a product:
2278     a.  For an indication not approved in labeling;
2279     b.  To comply with certain clinical guidelines; or
2280     c.  If the product has the potential for overuse, misuse,
2281or abuse.
2283The agency may require the prescribing professional to provide
2284information about the rationale and supporting medical evidence
2285for the use of a drug. The agency may post prior authorization
2286criteria and protocol and updates to the list of drugs that are
2287subject to prior authorization on an Internet website without
2288amending its rule or engaging in additional rulemaking.
2289     15.  The agency, in conjunction with the Pharmaceutical and
2290Therapeutics Committee, may require age-related prior
2291authorizations for certain prescribed drugs. The agency may
2292preauthorize the use of a drug for a recipient who may not meet
2293the age requirement or may exceed the length of therapy for use
2294of this product as recommended by the manufacturer and approved
2295by the Food and Drug Administration. Prior authorization may
2296require the prescribing professional to provide information
2297about the rationale and supporting medical evidence for the use
2298of a drug.
2299     16.  The agency shall implement a step-therapy prior
2300authorization approval process for medications excluded from the
2301preferred drug list. Medications listed on the preferred drug
2302list must be used within the previous 12 months prior to the
2303alternative medications that are not listed. The step-therapy
2304prior authorization may require the prescriber to use the
2305medications of a similar drug class or for a similar medical
2306indication unless contraindicated in the Food and Drug
2307Administration labeling. The trial period between the specified
2308steps may vary according to the medical indication. The step-
2309therapy approval process shall be developed in accordance with
2310the committee as stated in s. 409.91195(7) and (8). A drug
2311product may be approved without meeting the step-therapy prior
2312authorization criteria if the prescribing physician provides the
2313agency with additional written medical or clinical documentation
2314that the product is medically necessary because:
2315     a.  There is not a drug on the preferred drug list to treat
2316the disease or medical condition which is an acceptable clinical
2318     b.  The alternatives have been ineffective in the treatment
2319of the beneficiary's disease; or
2320     c.  Based on historic evidence and known characteristics of
2321the patient and the drug, the drug is likely to be ineffective,
2322or the number of doses have been ineffective.
2324The agency shall work with the physician to determine the best
2325alternative for the patient. The agency may adopt rules waiving
2326the requirements for written clinical documentation for specific
2327drugs in limited clinical situations.
2328     17.  The agency shall implement a return and reuse program
2329for drugs dispensed by pharmacies to institutional recipients,
2330which includes payment of a $5 restocking fee for the
2331implementation and operation of the program. The return and
2332reuse program shall be implemented electronically and in a
2333manner that promotes efficiency. The program must permit a
2334pharmacy to exclude drugs from the program if it is not
2335practical or cost-effective for the drug to be included and must
2336provide for the return to inventory of drugs that cannot be
2337credited or returned in a cost-effective manner. The agency
2338shall determine if the program has reduced the amount of
2339Medicaid prescription drugs which are destroyed on an annual
2340basis and if there are additional ways to ensure more
2341prescription drugs are not destroyed which could safely be
2342reused. The agency's conclusion and recommendations shall be
2343reported to the Legislature by December 1, 2005.
2344     (b)  The agency shall implement this subsection to the
2345extent that funds are appropriated to administer the Medicaid
2346prescribed-drug spending-control program. The agency may
2347contract all or any part of this program to private
2349     (c)  The agency shall submit quarterly reports to the
2350Governor, the President of the Senate, and the Speaker of the
2351House of Representatives which must include, but need not be
2352limited to, the progress made in implementing this subsection
2353and its effect on Medicaid prescribed-drug expenditures.
2354     (38)(40)  Notwithstanding the provisions of chapter 287,
2355the agency may, at its discretion, renew a contract or contracts
2356for fiscal intermediary services one or more times for such
2357periods as the agency may decide; however, all such renewals may
2358not combine to exceed a total period longer than the term of the
2359original contract.
2360     (39)(41)  The agency shall provide for the development of a
2361demonstration project by establishment in Miami-Dade County of a
2362long-term-care facility licensed pursuant to chapter 395 to
2363improve access to health care for a predominantly minority,
2364medically underserved, and medically complex population and to
2365evaluate alternatives to nursing home care and general acute
2366care for such population. Such project is to be located in a
2367health care condominium and colocated with licensed facilities
2368providing a continuum of care. The establishment of this project
2369is not subject to the provisions of s. 408.036 or s. 408.039.
2370This subsection expires October 1, 2013.
2371     (40)(42)  The agency shall develop and implement a
2372utilization management program for Medicaid-eligible recipients
2373for the management of occupational, physical, respiratory, and
2374speech therapies. The agency shall establish a utilization
2375program that may require prior authorization in order to ensure
2376medically necessary and cost-effective treatments. The program
2377shall be operated in accordance with a federally approved waiver
2378program or state plan amendment. The agency may seek a federal
2379waiver or state plan amendment to implement this program. The
2380agency may also competitively procure these services from an
2381outside vendor on a regional or statewide basis. This subsection
2382expires October 1, 2014.
2383     (41)(43)  The agency shall may contract on a prepaid or
2384fixed-sum basis with appropriately licensed prepaid dental
2385health plans to provide dental services. This subsection expires
2386October 1, 2014.
2387     (42)(44)  The Agency for Health Care Administration shall
2388ensure that any Medicaid managed care plan as defined in s.
2389409.9122(2)(f), whether paid on a capitated basis or a shared
2390savings basis, is cost-effective. For purposes of this
2391subsection, the term "cost-effective" means that a network's
2392per-member, per-month costs to the state, including, but not
2393limited to, fee-for-service costs, administrative costs, and
2394case-management fees, if any, must be no greater than the
2395state's costs associated with contracts for Medicaid services
2396established under subsection (3), which may be adjusted for
2397health status. The agency shall conduct actuarially sound
2398adjustments for health status in order to ensure such cost-
2399effectiveness and shall annually publish the results on its
2400Internet website. Contracts established pursuant to this
2401subsection which are not cost-effective may not be renewed. This
2402subsection expires October 1, 2014.
2403     (43)(45)  Subject to the availability of funds, the agency
2404shall mandate a recipient's participation in a provider lock-in
2405program, when appropriate, if a recipient is found by the agency
2406to have used Medicaid goods or services at a frequency or amount
2407not medically necessary, limiting the receipt of goods or
2408services to medically necessary providers after the 21-day
2409appeal process has ended, for a period of not less than 1 year.
2410The lock-in programs shall include, but are not limited to,
2411pharmacies, medical doctors, and infusion clinics. The
2412limitation does not apply to emergency services and care
2413provided to the recipient in a hospital emergency department.
2414The agency shall seek any federal waivers necessary to implement
2415this subsection. The agency shall adopt any rules necessary to
2416comply with or administer this subsection. This subsection
2417expires October 1, 2014.
2418     (44)(46)  The agency shall seek a federal waiver for
2419permission to terminate the eligibility of a Medicaid recipient
2420who has been found to have committed fraud, through judicial or
2421administrative determination, two times in a period of 5 years.
2422     (47)  The agency shall conduct a study of available
2423electronic systems for the purpose of verifying the identity and
2424eligibility of a Medicaid recipient. The agency shall recommend
2425to the Legislature a plan to implement an electronic
2426verification system for Medicaid recipients by January 31, 2005.
2427     (45)(48)(a)  A provider is not entitled to enrollment in
2428the Medicaid provider network. The agency may implement a
2429Medicaid fee-for-service provider network controls, including,
2430but not limited to, competitive procurement and provider
2431credentialing. If a credentialing process is used, the agency
2432may limit its provider network based upon the following
2433considerations: beneficiary access to care, provider
2434availability, provider quality standards and quality assurance
2435processes, cultural competency, demographic characteristics of
2436beneficiaries, practice standards, service wait times, provider
2437turnover, provider licensure and accreditation history, program
2438integrity history, peer review, Medicaid policy and billing
2439compliance records, clinical and medical record audit findings,
2440and such other areas that are considered necessary by the agency
2441to ensure the integrity of the program.
2442     (b)  The agency shall limit its network of durable medical
2443equipment and medical supply providers. For dates of service
2444after January 1, 2009, the agency shall limit payment for
2445durable medical equipment and supplies to providers that meet
2446all the requirements of this paragraph.
2447     1.  Providers must be accredited by a Centers for Medicare
2448and Medicaid Services deemed accreditation organization for
2449suppliers of durable medical equipment, prosthetics, orthotics,
2450and supplies. The provider must maintain accreditation and is
2451subject to unannounced reviews by the accrediting organization.
2452     2.  Providers must provide the services or supplies
2453directly to the Medicaid recipient or caregiver at the provider
2454location or recipient's residence or send the supplies directly
2455to the recipient's residence with receipt of mailed delivery.
2456Subcontracting or consignment of the service or supply to a
2457third party is prohibited.
2458     3.  Notwithstanding subparagraph 2., a durable medical
2459equipment provider may store nebulizers at a physician's office
2460for the purpose of having the physician's staff issue the
2461equipment if it meets all of the following conditions:
2462     a.  The physician must document the medical necessity and
2463need to prevent further deterioration of the patient's
2464respiratory status by the timely delivery of the nebulizer in
2465the physician's office.
2466     b.  The durable medical equipment provider must have
2467written documentation of the competency and training by a
2468Florida-licensed registered respiratory therapist of any durable
2469medical equipment staff who participate in the training of
2470physician office staff for the use of nebulizers, including
2471cleaning, warranty, and special needs of patients.
2472     c.  The physician's office must have documented the
2473training and competency of any staff member who initiates the
2474delivery of nebulizers to patients. The durable medical
2475equipment provider must maintain copies of all physician office
2477     d.  The physician's office must maintain inventory records
2478of stored nebulizers, including documentation of the durable
2479medical equipment provider source.
2480     e.  A physician contracted with a Medicaid durable medical
2481equipment provider may not have a financial relationship with
2482that provider or receive any financial gain from the delivery of
2483nebulizers to patients.
2484     4.  Providers must have a physical business location and a
2485functional landline business phone. The location must be within
2486the state or not more than 50 miles from the Florida state line.
2487The agency may make exceptions for providers of durable medical
2488equipment or supplies not otherwise available from other
2489enrolled providers located within the state.
2490     5.  Physical business locations must be clearly identified
2491as a business that furnishes durable medical equipment or
2492medical supplies by signage that can be read from 20 feet away.
2493The location must be readily accessible to the public during
2494normal, posted business hours and must operate at least 5 hours
2495per day and at least 5 days per week, with the exception of
2496scheduled and posted holidays. The location may not be located
2497within or at the same numbered street address as another
2498enrolled Medicaid durable medical equipment or medical supply
2499provider or as an enrolled Medicaid pharmacy that is also
2500enrolled as a durable medical equipment provider. A licensed
2501orthotist or prosthetist that provides only orthotic or
2502prosthetic devices as a Medicaid durable medical equipment
2503provider is exempt from this paragraph.
2504     6.  Providers must maintain a stock of durable medical
2505equipment and medical supplies on site that is readily available
2506to meet the needs of the durable medical equipment business
2507location's customers.
2508     7.  Providers must provide a surety bond of $50,000 for
2509each provider location, up to a maximum of 5 bonds statewide or
2510an aggregate bond of $250,000 statewide, as identified by
2511Federal Employer Identification Number. Providers who post a
2512statewide or an aggregate bond must identify all of their
2513locations in any Medicaid durable medical equipment and medical
2514supply provider enrollment application or bond renewal. Each
2515provider location's surety bond must be renewed annually and the
2516provider must submit proof of renewal even if the original bond
2517is a continuous bond. A licensed orthotist or prosthetist that
2518provides only orthotic or prosthetic devices as a Medicaid
2519durable medical equipment provider is exempt from the provisions
2520in this paragraph.
2521     8.  Providers must obtain a level 2 background screening,
2522in accordance with chapter 435 and s. 408.809, for each provider
2523employee in direct contact with or providing direct services to
2524recipients of durable medical equipment and medical supplies in
2525their homes. This requirement includes, but is not limited to,
2526repair and service technicians, fitters, and delivery staff. The
2527provider shall pay for the cost of the background screening.
2528     9.  The following providers are exempt from subparagraphs
25291. and 7.:
2530     a.  Durable medical equipment providers owned and operated
2531by a government entity.
2532     b.  Durable medical equipment providers that are operating
2533within a pharmacy that is currently enrolled as a Medicaid
2534pharmacy provider.
2535     c.  Active, Medicaid-enrolled orthopedic physician groups,
2536primarily owned by physicians, which provide only orthotic and
2537prosthetic devices.
2538     (46)(49)  The agency shall contract with established
2539minority physician networks that provide services to
2540historically underserved minority patients. The networks must
2541provide cost-effective Medicaid services, comply with the
2542requirements to be a MediPass provider, and provide their
2543primary care physicians with access to data and other management
2544tools necessary to assist them in ensuring the appropriate use
2545of services, including inpatient hospital services and
2547     (a)  The agency shall provide for the development and
2548expansion of minority physician networks in each service area to
2549provide services to Medicaid recipients who are eligible to
2550participate under federal law and rules.
2551     (b)  The agency shall reimburse each minority physician
2552network as a fee-for-service provider, including the case
2553management fee for primary care, if any, or as a capitated rate
2554provider for Medicaid services. Any savings shall be shared with
2555the minority physician networks pursuant to the contract.
2556     (c)  For purposes of this subsection, the term "cost-
2557effective" means that a network's per-member, per-month costs to
2558the state, including, but not limited to, fee-for-service costs,
2559administrative costs, and case-management fees, if any, must be
2560no greater than the state's costs associated with contracts for
2561Medicaid services established under subsection (3), which shall
2562be actuarially adjusted for case mix, model, and service area.
2563The agency shall conduct actuarially sound audits adjusted for
2564case mix and model in order to ensure such cost-effectiveness
2565and shall annually publish the audit results on its Internet
2566website. Contracts established pursuant to this subsection which
2567are not cost-effective may not be renewed.
2568     (d)  The agency may apply for any federal waivers needed to
2569implement this subsection.
2571This subsection expires October 1, 2014.
2572     (47)(50)  To the extent permitted by federal law and as
2573allowed under s. 409.906, the agency shall provide reimbursement
2574for emergency mental health care services for Medicaid
2575recipients in crisis stabilization facilities licensed under s.
2576394.875 as long as those services are less expensive than the
2577same services provided in a hospital setting.
2578     (48)(51)  The agency shall work with the Agency for Persons
2579with Disabilities to develop a home and community-based waiver
2580to serve children and adults who are diagnosed with familial
2581dysautonomia or Riley-Day syndrome caused by a mutation of the
2582IKBKAP gene on chromosome 9. The agency shall seek federal
2583waiver approval and implement the approved waiver subject to the
2584availability of funds and any limitations provided in the
2585General Appropriations Act. The agency may adopt rules to
2586implement this waiver program.
2587     (49)(52)  The agency shall implement a program of all-
2588inclusive care for children. The program of all-inclusive care
2589for children shall be established to provide in-home hospice-
2590like support services to children diagnosed with a life-
2591threatening illness and enrolled in the Children's Medical
2592Services network to reduce hospitalizations as appropriate. The
2593agency, in consultation with the Department of Health, may
2594implement the program of all-inclusive care for children after
2595obtaining approval from the Centers for Medicare and Medicaid
2597     (50)(53)  Before seeking an amendment to the state plan for
2598purposes of implementing programs authorized by the Deficit
2599Reduction Act of 2005, the agency shall notify the Legislature.
2600     Section 14.  Section 409.91207, Florida Statutes, is
2602     Section 15.  Paragraphs (e), (l), (p), (w), and (dd) of
2603subsection (3) of section 409.91211, Florida Statutes, are
2604amended to read:
2605     409.91211  Medicaid managed care pilot program.-
2606     (3)  The agency shall have the following powers, duties,
2607and responsibilities with respect to the pilot program:
2608     (e)  To implement policies and guidelines for phasing in
2609financial risk for approved provider service networks that, for
2610purposes of this paragraph, include the Children's Medical
2611Services Network, over the period of the waiver and the
2612extension thereof. These policies and guidelines must include an
2613option for a provider service network to be paid fee-for-service
2614rates. For any provider service network established in a managed
2615care pilot area, the option to be paid fee-for-service rates
2616must include a savings-settlement mechanism that is consistent
2617with s. 409.912(42)(44). This model must be converted to a risk-
2618adjusted capitated rate by the beginning of the final year of
2619operation under the waiver extension, and may be converted
2620earlier at the option of the provider service network. Federally
2621qualified health centers may be offered an opportunity to accept
2622or decline a contract to participate in any provider network for
2623prepaid primary care services.
2624     (l)  To implement a system that prohibits capitated managed
2625care plans, their representatives, and providers employed by or
2626contracted with the capitated managed care plans from recruiting
2627persons eligible for or enrolled in Medicaid, from providing
2628inducements to Medicaid recipients to select a particular
2629capitated managed care plan, and from prejudicing Medicaid
2630recipients against other capitated managed care plans. The
2631system shall require the entity performing choice counseling to
2632determine if the recipient has made a choice of a plan or has
2633opted out because of duress, threats, payment to the recipient,
2634or incentives promised to the recipient by a third party. If the
2635choice counseling entity determines that the decision to choose
2636a plan was unlawfully influenced or a plan violated any of the
2637provisions of s. 409.912(20)(21), the choice counseling entity
2638shall immediately report the violation to the agency's program
2639integrity section for investigation. Verification of choice
2640counseling by the recipient shall include a stipulation that the
2641recipient acknowledges the provisions of this subsection.
2642     (p)  To implement standards for plan compliance, including,
2643but not limited to, standards for quality assurance and
2644performance improvement, standards for peer or professional
2645reviews, grievance policies, and policies for maintaining
2646program integrity. The agency shall develop a data-reporting
2647system, seek input from managed care plans in order to establish
2648requirements for patient-encounter reporting, and ensure that
2649the data reported is accurate and complete.
2650     1.  In performing the duties required under this section,
2651the agency shall work with managed care plans to establish a
2652uniform system to measure and monitor outcomes for a recipient
2653of Medicaid services.
2654     2.  The system shall use financial, clinical, and other
2655criteria based on pharmacy, medical services, and other data
2656that is related to the provision of Medicaid services,
2657including, but not limited to:
2658     a.  The Health Plan Employer Data and Information Set
2659(HEDIS) or measures that are similar to HEDIS.
2660     b.  Member satisfaction.
2661     c.  Provider satisfaction.
2662     d.  Report cards on plan performance and best practices.
2663     e.  Compliance with the requirements for prompt payment of
2664claims under ss. 627.613, 641.3155, and 641.513.
2665     f.  Utilization and quality data for the purpose of
2666ensuring access to medically necessary services, including
2667underutilization or inappropriate denial of services.
2668     3.  The agency shall require the managed care plans that
2669have contracted with the agency to establish a quality assurance
2670system that incorporates the provisions of s. 409.912(26)(27)
2671and any standards, rules, and guidelines developed by the
2673     4.  The agency shall establish an encounter database in
2674order to compile data on health services rendered by health care
2675practitioners who provide services to patients enrolled in
2676managed care plans in the demonstration sites. The encounter
2677database shall:
2678     a.  Collect the following for each type of patient
2679encounter with a health care practitioner or facility,
2681     (I)  The demographic characteristics of the patient.
2682     (II)  The principal, secondary, and tertiary diagnosis.
2683     (III)  The procedure performed.
2684     (IV)  The date and location where the procedure was
2686     (V)  The payment for the procedure, if any.
2687     (VI)  If applicable, the health care practitioner's
2688universal identification number.
2689     (VII)  If the health care practitioner rendering the
2690service is a dependent practitioner, the modifiers appropriate
2691to indicate that the service was delivered by the dependent
2693     b.  Collect appropriate information relating to
2694prescription drugs for each type of patient encounter.
2695     c.  Collect appropriate information related to health care
2696costs and utilization from managed care plans participating in
2697the demonstration sites.
2698     5.  To the extent practicable, when collecting the data the
2699agency shall use a standardized claim form or electronic
2700transfer system that is used by health care practitioners,
2701facilities, and payors.
2702     6.  Health care practitioners and facilities in the
2703demonstration sites shall electronically submit, and managed
2704care plans participating in the demonstration sites shall
2705electronically receive, information concerning claims payments
2706and any other information reasonably related to the encounter
2707database using a standard format as required by the agency.
2708     7.  The agency shall establish reasonable deadlines for
2709phasing in the electronic transmittal of full encounter data.
2710     8.  The system must ensure that the data reported is
2711accurate and complete.
2712     (w)  To implement procedures to minimize the risk of
2713Medicaid fraud and abuse in all plans operating in the Medicaid
2714managed care pilot program authorized in this section.
2715     1.  The agency shall ensure that applicable provisions of
2716this chapter and chapters 414, 626, 641, and 932 which relate to
2717Medicaid fraud and abuse are applied and enforced at the
2718demonstration project sites.
2719     2.  Providers must have the certification, license, and
2720credentials that are required by law and waiver requirements.
2721     3.  The agency shall ensure that the plan is in compliance
2722with s. 409.912(20) and (21) and (22).
2723     4.  The agency shall require that each plan establish
2724functions and activities governing program integrity in order to
2725reduce the incidence of fraud and abuse. Plans must report
2726instances of fraud and abuse pursuant to chapter 641.
2727     5.  The plan shall have written administrative and
2728management arrangements or procedures, including a mandatory
2729compliance plan, which are designed to guard against fraud and
2730abuse. The plan shall designate a compliance officer who has
2731sufficient experience in health care.
2732     6.a.  The agency shall require all managed care plan
2733contractors in the pilot program to report all instances of
2734suspected fraud and abuse. A failure to report instances of
2735suspected fraud and abuse is a violation of law and subject to
2736the penalties provided by law.
2737     b.  An instance of fraud and abuse in the managed care
2738plan, including, but not limited to, defrauding the state health
2739care benefit program by misrepresentation of fact in reports,
2740claims, certifications, enrollment claims, demographic
2741statistics, or patient-encounter data; misrepresentation of the
2742qualifications of persons rendering health care and ancillary
2743services; bribery and false statements relating to the delivery
2744of health care; unfair and deceptive marketing practices; and
2745false claims actions in the provision of managed care, is a
2746violation of law and subject to the penalties provided by law.
2747     c.  The agency shall require that all contractors make all
2748files and relevant billing and claims data accessible to state
2749regulators and investigators and that all such data is linked
2750into a unified system to ensure consistent reviews and
2752     (dd)  To implement service delivery mechanisms within a
2753specialty plan in area 10 to provide behavioral health care
2754services to Medicaid-eligible children whose cases are open for
2755child welfare services in the HomeSafeNet system. These services
2756must be coordinated with community-based care providers as
2757specified in s. 409.1671, where available, and be sufficient to
2758meet the developmental, behavioral, and emotional needs of these
2759children. Children in area 10 who have an open case in the
2760HomeSafeNet system shall be enrolled into the specialty plan.
2761These service delivery mechanisms must be implemented no later
2762than July 1, 2011, in AHCA area 10 in order for the children in
2763AHCA area 10 to remain exempt from the statewide plan under s.
2764409.912(4)(b)5.8. An administrative fee may be paid to the
2765specialty plan for the coordination of services based on the
2766receipt of the state share of that fee being provided through
2767intergovernmental transfers.
2768     Section 16.  Effective October 1, 2014, section 409.91211,
2769Florida Statutes, is repealed.
2770     Section 17.  Section 409.9122, Florida Statutes, is amended
2771to read:
2772     409.9122  Mandatory Medicaid managed care enrollment;
2773programs and procedures.-
2774     (1)  It is the intent of the Legislature that the MediPass
2775program be cost-effective, provide quality health care, and
2776improve access to health services, and that the program be
2777statewide. This subsection expires October 1, 2014.
2778     (2)(a)  The agency shall enroll in a managed care plan or
2779MediPass all Medicaid recipients, except those Medicaid
2780recipients who are: in an institution; enrolled in the Medicaid
2781medically needy program; or eligible for both Medicaid and
2782Medicare. Upon enrollment, individuals will be able to change
2783their managed care option during the 90-day opt out period
2784required by federal Medicaid regulations. The agency is
2785authorized to seek the necessary Medicaid state plan amendment
2786to implement this policy. However, to the extent permitted by
2787federal law, the agency may enroll in a managed care plan or
2788MediPass a Medicaid recipient who is exempt from mandatory
2789managed care enrollment, provided that:
2790     1.  The recipient's decision to enroll in a managed care
2791plan or MediPass is voluntary;
2792     2.  If the recipient chooses to enroll in a managed care
2793plan, the agency has determined that the managed care plan
2794provides specific programs and services which address the
2795special health needs of the recipient; and
2796     3.  The agency receives any necessary waivers from the
2797federal Centers for Medicare and Medicaid Services.
2799The agency shall develop rules to establish policies by which
2800exceptions to the mandatory managed care enrollment requirement
2801may be made on a case-by-case basis. The rules shall include the
2802specific criteria to be applied when making a determination as
2803to whether to exempt a recipient from mandatory enrollment in a
2804managed care plan or MediPass. School districts participating in
2805the certified school match program pursuant to ss. 409.908(21)
2806and 1011.70 shall be reimbursed by Medicaid, subject to the
2807limitations of s. 1011.70(1), for a Medicaid-eligible child
2808participating in the services as authorized in s. 1011.70, as
2809provided for in s. 409.9071, regardless of whether the child is
2810enrolled in MediPass or a managed care plan. Managed care plans
2811shall make a good faith effort to execute agreements with school
2812districts regarding the coordinated provision of services
2813authorized under s. 1011.70. County health departments
2814delivering school-based services pursuant to ss. 381.0056 and
2815381.0057 shall be reimbursed by Medicaid for the federal share
2816for a Medicaid-eligible child who receives Medicaid-covered
2817services in a school setting, regardless of whether the child is
2818enrolled in MediPass or a managed care plan. Managed care plans
2819shall make a good faith effort to execute agreements with county
2820health departments regarding the coordinated provision of
2821services to a Medicaid-eligible child. To ensure continuity of
2822care for Medicaid patients, the agency, the Department of
2823Health, and the Department of Education shall develop procedures
2824for ensuring that a student's managed care plan or MediPass
2825provider receives information relating to services provided in
2826accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2827     (b)  A Medicaid recipient shall not be enrolled in or
2828assigned to a managed care plan or MediPass unless the managed
2829care plan or MediPass has complied with the quality-of-care
2830standards specified in paragraphs (3)(a) and (b), respectively.
2831     (c)  Medicaid recipients shall have a choice of managed
2832care plans or MediPass. The Agency for Health Care
2833Administration, the Department of Health, the Department of
2834Children and Family Services, and the Department of Elderly
2835Affairs shall cooperate to ensure that each Medicaid recipient
2836receives clear and easily understandable information that meets
2837the following requirements:
2838     1.  Explains the concept of managed care, including
2840     2.  Provides information on the comparative performance of
2841managed care plans and MediPass in the areas of quality,
2842credentialing, preventive health programs, network size and
2843availability, and patient satisfaction.
2844     3.  Explains where additional information on each managed
2845care plan and MediPass in the recipient's area can be obtained.
2846     4.  Explains that recipients have the right to choose their
2847managed care coverage at the time they first enroll in Medicaid
2848and again at regular intervals set by the agency. However, if a
2849recipient does not choose a managed care plan or MediPass, the
2850agency will assign the recipient to a managed care plan or
2851MediPass according to the criteria specified in this section.
2852     5.  Explains the recipient's right to complain, file a
2853grievance, or change managed care plans or MediPass providers if
2854the recipient is not satisfied with the managed care plan or
2856     (d)  The agency shall develop a mechanism for providing
2857information to Medicaid recipients for the purpose of making a
2858managed care plan or MediPass selection. Examples of such
2859mechanisms may include, but not be limited to, interactive
2860information systems, mailings, and mass marketing materials.
2861Managed care plans and MediPass providers are prohibited from
2862providing inducements to Medicaid recipients to select their
2863plans or from prejudicing Medicaid recipients against other
2864managed care plans or MediPass providers.
2865     (e)  Medicaid recipients who are already enrolled in a
2866managed care plan or MediPass shall be offered the opportunity
2867to change managed care plans or MediPass providers on a
2868staggered basis, as defined by the agency. All Medicaid
2869recipients shall have 30 days in which to make a choice of
2870managed care plans or MediPass providers. Those Medicaid
2871recipients who do not make a choice shall be assigned in
2872accordance with paragraph (f). To facilitate continuity of care,
2873for a Medicaid recipient who is also a recipient of Supplemental
2874Security Income (SSI), prior to assigning the SSI recipient to a
2875managed care plan or MediPass, the agency shall determine
2876whether the SSI recipient has an ongoing relationship with a
2877MediPass provider or managed care plan, and if so, the agency
2878shall assign the SSI recipient to that MediPass provider or
2879managed care plan. Those SSI recipients who do not have such a
2880provider relationship shall be assigned to a managed care plan
2881or MediPass provider in accordance with paragraph (f).
2882     (f)  If a Medicaid recipient does not choose a managed care
2883plan or MediPass provider, the agency shall assign the Medicaid
2884recipient to a managed care plan or MediPass provider. Medicaid
2885recipients eligible for managed care plan enrollment who are
2886subject to mandatory assignment but who fail to make a choice
2887shall be assigned to managed care plans until an enrollment of
288835 percent in MediPass and 65 percent in managed care plans, of
2889all those eligible to choose managed care, is achieved. Once
2890this enrollment is achieved, the assignments shall be divided in
2891order to maintain an enrollment in MediPass and managed care
2892plans which is in a 35 percent and 65 percent proportion,
2893respectively. Thereafter, assignment of Medicaid recipients who
2894fail to make a choice shall be based proportionally on the
2895preferences of recipients who have made a choice in the previous
2896period. Such proportions shall be revised at least quarterly to
2897reflect an update of the preferences of Medicaid recipients. The
2898agency shall disproportionately assign Medicaid-eligible
2899recipients who are required to but have failed to make a choice
2900of managed care plan or MediPass, including children, and who
2901would be assigned to the MediPass program to the children's
2902networks as described in s. 409.912(4)(g), Children's Medical
2903Services Network as defined in s. 391.021, exclusive provider
2904organizations, provider service networks, minority physician
2905networks, and pediatric emergency department diversion programs
2906authorized by this chapter or the General Appropriations Act, in
2907such manner as the agency deems appropriate, until the agency
2908has determined that the networks and programs have sufficient
2909numbers to be operated economically. For purposes of this
2910paragraph, when referring to assignment, the term "managed care
2911plans" includes health maintenance organizations, exclusive
2912provider organizations, provider service networks, minority
2913physician networks, Children's Medical Services Network, and
2914pediatric emergency department diversion programs authorized by
2915this chapter or the General Appropriations Act. When making
2916assignments, the agency shall take into account the following
2918     1.  A managed care plan has sufficient network capacity to
2919meet the need of members.
2920     2.  The managed care plan or MediPass has previously
2921enrolled the recipient as a member, or one of the managed care
2922plan's primary care providers or MediPass providers has
2923previously provided health care to the recipient.
2924     3.  The agency has knowledge that the member has previously
2925expressed a preference for a particular managed care plan or
2926MediPass provider as indicated by Medicaid fee-for-service
2927claims data, but has failed to make a choice.
2928     4.  The managed care plan's or MediPass primary care
2929providers are geographically accessible to the recipient's
2931     (g)  When more than one managed care plan or MediPass
2932provider meets the criteria specified in paragraph (f), the
2933agency shall make recipient assignments consecutively by family
2935     (h)  The agency may not engage in practices that are
2936designed to favor one managed care plan over another or that are
2937designed to influence Medicaid recipients to enroll in MediPass
2938rather than in a managed care plan or to enroll in a managed
2939care plan rather than in MediPass. This subsection does not
2940prohibit the agency from reporting on the performance of
2941MediPass or any managed care plan, as measured by performance
2942criteria developed by the agency.
2943     (i)  After a recipient has made his or her selection or has
2944been enrolled in a managed care plan or MediPass, the recipient
2945shall have 90 days to exercise the opportunity to voluntarily
2946disenroll and select another managed care plan or MediPass.
2947After 90 days, no further changes may be made except for good
2948cause. Good cause includes, but is not limited to, poor quality
2949of care, lack of access to necessary specialty services, an
2950unreasonable delay or denial of service, or fraudulent
2951enrollment. The agency shall develop criteria for good cause
2952disenrollment for chronically ill and disabled populations who
2953are assigned to managed care plans if more appropriate care is
2954available through the MediPass program. The agency must make a
2955determination as to whether cause exists. However, the agency
2956may require a recipient to use the managed care plan's or
2957MediPass grievance process prior to the agency's determination
2958of cause, except in cases in which immediate risk of permanent
2959damage to the recipient's health is alleged. The grievance
2960process, when utilized, must be completed in time to permit the
2961recipient to disenroll by the first day of the second month
2962after the month the disenrollment request was made. If the
2963managed care plan or MediPass, as a result of the grievance
2964process, approves an enrollee's request to disenroll, the agency
2965is not required to make a determination in the case. The agency
2966must make a determination and take final action on a recipient's
2967request so that disenrollment occurs no later than the first day
2968of the second month after the month the request was made. If the
2969agency fails to act within the specified timeframe, the
2970recipient's request to disenroll is deemed to be approved as of
2971the date agency action was required. Recipients who disagree
2972with the agency's finding that cause does not exist for
2973disenrollment shall be advised of their right to pursue a
2974Medicaid fair hearing to dispute the agency's finding.
2975     (j)  The agency shall apply for a federal waiver from the
2976Centers for Medicare and Medicaid Services to lock eligible
2977Medicaid recipients into a managed care plan or MediPass for 12
2978months after an open enrollment period. After 12 months'
2979enrollment, a recipient may select another managed care plan or
2980MediPass provider. However, nothing shall prevent a Medicaid
2981recipient from changing primary care providers within the
2982managed care plan or MediPass program during the 12-month
2984     (k)  When a Medicaid recipient does not choose a managed
2985care plan or MediPass provider, the agency shall assign the
2986Medicaid recipient to a managed care plan, except in those
2987counties in which there are fewer than two managed care plans
2988accepting Medicaid enrollees, in which case assignment shall be
2989to a managed care plan or a MediPass provider. Medicaid
2990recipients in counties with fewer than two managed care plans
2991accepting Medicaid enrollees who are subject to mandatory
2992assignment but who fail to make a choice shall be assigned to
2993managed care plans until an enrollment of 35 percent in MediPass
2994and 65 percent in managed care plans, of all those eligible to
2995choose managed care, is achieved. Once that enrollment is
2996achieved, the assignments shall be divided in order to maintain
2997an enrollment in MediPass and managed care plans which is in a
299835 percent and 65 percent proportion, respectively. For purposes
2999of this paragraph, when referring to assignment, the term
3000"managed care plans" includes exclusive provider organizations,
3001provider service networks, Children's Medical Services Network,
3002minority physician networks, and pediatric emergency department
3003diversion programs authorized by this chapter or the General
3004Appropriations Act. When making assignments, the agency shall
3005take into account the following criteria:
3006     1.  A managed care plan has sufficient network capacity to
3007meet the need of members.
3008     2.  The managed care plan or MediPass has previously
3009enrolled the recipient as a member, or one of the managed care
3010plan's primary care providers or MediPass providers has
3011previously provided health care to the recipient.
3012     3.  The agency has knowledge that the member has previously
3013expressed a preference for a particular managed care plan or
3014MediPass provider as indicated by Medicaid fee-for-service
3015claims data, but has failed to make a choice.
3016     4.  The managed care plan's or MediPass primary care
3017providers are geographically accessible to the recipient's
3019     5.  The agency has authority to make mandatory assignments
3020based on quality of service and performance of managed care
3022     (l)  Notwithstanding the provisions of chapter 287, the
3023agency may, at its discretion, renew cost-effective contracts
3024for choice counseling services once or more for such periods as
3025the agency may decide. However, all such renewals may not
3026combine to exceed a total period longer than the term of the
3027original contract.
3029This subsection expires October 1, 2014.
3030     (3)(a)  The agency shall establish quality-of-care
3031standards for managed care plans. These standards shall be based
3032upon, but are not limited to:
3033     1.  Compliance with the accreditation requirements as
3034provided in s. 641.512.
3035     2.  Compliance with Early and Periodic Screening,
3036Diagnosis, and Treatment screening requirements.
3037     3.  The percentage of voluntary disenrollments.
3038     4.  Immunization rates.
3039     5.  Standards of the National Committee for Quality
3040Assurance and other approved accrediting bodies.
3041     6.  Recommendations of other authoritative bodies.
3042     7.  Specific requirements of the Medicaid program, or
3043standards designed to specifically assist the unique needs of
3044Medicaid recipients.
3045     8.  Compliance with the health quality improvement system
3046as established by the agency, which incorporates standards and
3047guidelines developed by the Medicaid Bureau of the Health Care
3048Financing Administration as part of the quality assurance reform
3050     (b)  For the MediPass program, the agency shall establish
3051standards which are based upon, but are not limited to:
3052     1.  Quality-of-care standards which are comparable to those
3053required of managed care plans.
3054     2.  Credentialing standards for MediPass providers.
3055     3.  Compliance with Early and Periodic Screening,
3056Diagnosis, and Treatment screening requirements.
3057     4.  Immunization rates.
3058     5.  Specific requirements of the Medicaid program, or
3059standards designed to specifically assist the unique needs of
3060Medicaid recipients.
3062This subsection expires October 1, 2014.
3063     (4)(a)  Each female recipient may select as her primary
3064care provider an obstetrician/gynecologist who has agreed to
3065participate as a MediPass primary care case manager.
3066     (b)  The agency shall establish a complaints and grievance
3067process to assist Medicaid recipients enrolled in the MediPass
3068program to resolve complaints and grievances. The agency shall
3069investigate reports of quality-of-care grievances which remain
3070unresolved to the satisfaction of the enrollee.
3072This subsection expires October 1, 2014.
3073     (5)(a)  The agency shall work cooperatively with the Social
3074Security Administration to identify beneficiaries who are
3075jointly eligible for Medicare and Medicaid and shall develop
3076cooperative programs to encourage these beneficiaries to enroll
3077in a Medicare participating health maintenance organization or
3078prepaid health plans.
3079     (b)  The agency shall work cooperatively with the
3080Department of Elderly Affairs to assess the potential cost-
3081effectiveness of providing MediPass to beneficiaries who are
3082jointly eligible for Medicare and Medicaid on a voluntary choice
3083basis. If the agency determines that enrollment of these
3084beneficiaries in MediPass has the potential for being cost-
3085effective for the state, the agency shall offer MediPass to
3086these beneficiaries on a voluntary choice basis in the counties
3087where MediPass operates.
3089This subsection expires October 1, 2014.
3090     (6)  MediPass enrolled recipients may receive up to 10
3091visits of reimbursable services by participating Medicaid
3092physicians licensed under chapter 460 and up to four visits of
3093reimbursable services by participating Medicaid physicians
3094licensed under chapter 461. Any further visits must be by prior
3095authorization by the MediPass primary care provider. However,
3096nothing in this subsection may be construed to increase the
3097total number of visits or the total amount of dollars per year
3098per person under current Medicaid rules, unless otherwise
3099provided for in the General Appropriations Act. This subsection
3100expires October 1, 2014.
3101     (7)  The agency shall investigate the feasibility of
3102developing managed care plan and MediPass options for the
3103following groups of Medicaid recipients:
3104     (a)  Pregnant women and infants.
3105     (b)  Elderly and disabled recipients, especially those who
3106are at risk of nursing home placement.
3107     (c)  Persons with developmental disabilities.
3108     (d)  Qualified Medicare beneficiaries.
3109     (e)  Adults who have chronic, high-cost medical conditions.
3110     (f)  Adults and children who have mental health problems.
3111     (g)  Other recipients for whom managed care plans and
3112MediPass offer the opportunity of more cost-effective care and
3113greater access to qualified providers.
3114     (8)(a)  The agency shall encourage the development of
3115public and private partnerships to foster the growth of health
3116maintenance organizations and prepaid health plans that will
3117provide high-quality health care to Medicaid recipients.
3118     (b)  Subject to the availability of moneys and any
3119limitations established by the General Appropriations Act or
3120chapter 216, the agency is authorized to enter into contracts
3121with traditional providers of health care to low-income persons
3122to assist such providers with the technical aspects of
3123cooperatively developing Medicaid prepaid health plans.
3124     1.  The agency may contract with disproportionate share
3125hospitals, county health departments, federally initiated or
3126federally funded community health centers, and counties that
3127operate either a hospital or a community clinic.
3128     2.  A contract may not be for more than $100,000 per year,
3129and no contract may be extended with any particular provider for
3130more than 2 years. The contract is intended only as seed or
3131development funding and requires a commitment from the
3132interested party.
3133     3.  A contract must require participation by at least one
3134community health clinic and one disproportionate share hospital.
3135     (7)(9)(a)  The agency shall develop and implement a
3136comprehensive plan to ensure that recipients are adequately
3137informed of their choices and rights under all Medicaid managed
3138care programs and that Medicaid managed care programs meet
3139acceptable standards of quality in patient care, patient
3140satisfaction, and financial solvency.
3141     (b)  The agency shall provide adequate means for informing
3142patients of their choice and rights under a managed care plan at
3143the time of eligibility determination.
3144     (c)  The agency shall require managed care plans and
3145MediPass providers to demonstrate and document plans and
3146activities, as defined by rule, including outreach and followup,
3147undertaken to ensure that Medicaid recipients receive the health
3148care service to which they are entitled.
3150This subsection expires October 1, 2014.
3151     (8)(10)  The agency shall consult with Medicaid consumers
3152and their representatives on an ongoing basis regarding
3153measurements of patient satisfaction, procedures for resolving
3154patient grievances, standards for ensuring quality of care,
3155mechanisms for providing patient access to services, and
3156policies affecting patient care. This subsection expires October
31571, 2014.
3158     (9)(11)  The agency may extend eligibility for Medicaid
3159recipients enrolled in licensed and accredited health
3160maintenance organizations for the duration of the enrollment
3161period or for 6 months, whichever is earlier, provided the
3162agency certifies that such an offer will not increase state
3163expenditures. This subsection expires October 1, 2013.
3164     (10)(12)  A managed care plan that has a Medicaid contract
3165shall at least annually review each primary care physician's
3166active patient load and shall ensure that additional Medicaid
3167recipients are not assigned to physicians who have a total
3168active patient load of more than 3,000 patients. As used in this
3169subsection, the term "active patient" means a patient who is
3170seen by the same primary care physician, or by a physician
3171assistant or advanced registered nurse practitioner under the
3172supervision of the primary care physician, at least three times
3173within a calendar year. Each primary care physician shall
3174annually certify to the managed care plan whether or not his or
3175her patient load exceeds the limits established under this
3176subsection and the managed care plan shall accept such
3177certification on face value as compliance with this subsection.
3178The agency shall accept the managed care plan's representations
3179that it is in compliance with this subsection based on the
3180certification of its primary care physicians, unless the agency
3181has an objective indication that access to primary care is being
3182compromised, such as receiving complaints or grievances relating
3183to access to care. If the agency determines that an objective
3184indication exists that access to primary care is being
3185compromised, it may verify the patient load certifications
3186submitted by the managed care plan's primary care physicians and
3187that the managed care plan is not assigning Medicaid recipients
3188to primary care physicians who have an active patient load of
3189more than 3,000 patients. This subsection expires October 1,
3191     (11)(13)  Effective July 1, 2003, the agency shall adjust
3192the enrollee assignment process of Medicaid managed prepaid
3193health plans for those Medicaid managed prepaid plans operating
3194in Miami-Dade County which have executed a contract with the
3195agency for a minimum of 8 consecutive years in order for the
3196Medicaid managed prepaid plan to maintain a minimum enrollment
3197level of 15,000 members per month. When assigning enrollees
3198pursuant to this subsection, the agency shall give priority to
3199providers that initially qualified under this subsection until
3200such providers reach and maintain an enrollment level of 15,000
3201members per month. A prepaid health plan that has a statewide
3202Medicaid enrollment of 25,000 or more members is not eligible
3203for enrollee assignments under this subsection. This subsection
3204expires October 1, 2014.
3205     (12)(14)  The agency shall include in its calculation of
3206the hospital inpatient component of a Medicaid health
3207maintenance organization's capitation rate any special payments,
3208including, but not limited to, upper payment limit or
3209disproportionate share hospital payments, made to qualifying
3210hospitals through the fee-for-service program. The agency may
3211seek federal waiver approval or state plan amendment as needed
3212to implement this adjustment.
3213     (13)  The agency shall develop a process to enable any
3214recipient with access to employer-sponsored health care coverage
3215to opt out of all eligible plans in the Medicaid program and to
3216use Medicaid financial assistance to pay for the recipient's
3217share of cost in any such employer-sponsored coverage.
3218Contingent on federal approval, the agency shall also enable
3219recipients with access to other insurance or related products
3220that provide access to health care services created pursuant to
3221state law, including any plan or product available pursuant to
3222the Florida Health Choices Program or any health exchange, to
3223opt out. The amount of financial assistance provided for each
3224recipient may not exceed the amount of the Medicaid premium that
3225would have been paid to a plan for that recipient.
3226     (14)  The agency shall maintain and operate the Medicaid
3227Encounter Data System to collect, process, store, and report on
3228covered services provided to all Florida Medicaid recipients
3229enrolled in prepaid managed care plans.
3230     (a)  Prepaid managed care plans shall submit encounter data
3231electronically in a format that complies with the Health
3232Insurance Portability and Accountability Act provisions for
3233electronic claims and in accordance with deadlines established
3234by the agency. Prepaid managed care plans must certify that the
3235data reported is accurate and complete.
3236     (b)  The agency is responsible for validating the data
3237submitted by the plans. The agency shall develop methods and
3238protocols for ongoing analysis of the encounter data that
3239adjusts for differences in characteristics of prepaid plan
3240enrollees to allow comparison of service utilization among plans
3241and against expected levels of use. The analysis shall be used
3242to identify possible cases of systemic underutilization or
3243denials of claims and inappropriate service utilization such as
3244higher-than-expected emergency department encounters. The
3245analysis shall provide periodic feedback to the plans and enable
3246the agency to establish corrective action plans when necessary.
3247One of the focus areas for the analysis shall be the use of
3248prescription drugs.
3249     (15)  The agency may establish a per-member, per-month
3250payment for Medicare Advantage Special Needs members that are
3251also eligible for Medicaid as a mechanism for meeting the
3252state's cost-sharing obligation. The agency may also develop a
3253per-member, per-month payment only for Medicaid-covered services
3254for which the state is responsible. The agency shall develop a
3255mechanism to ensure that such per-member, per-month payment
3256enhances the value to the state and enrolled members by limiting
3257cost sharing, enhances the scope of Medicare supplemental
3258benefits that are equal to or greater than Medicaid coverage for
3259select services, and improves care coordination.
3260     (16)  The agency shall establish, and managed care plans
3261shall use, a uniform method of accounting for and reporting
3262medical and nonmedical costs. The agency shall make such
3263information available to the public.
3264     (17)  The agency may, on a case-by-case basis, exempt a
3265recipient from mandatory enrollment in a managed care plan when
3266the recipient has a unique, time-limited disease or condition-
3267related circumstance and managed care enrollment will interfere
3268with ongoing care because the recipient's provider does not
3269participate in the managed care plans available in the
3270recipient's area.
3271     (18)  The agency shall contract with a single provider
3272service network to function as a third-party administrator and
3273managing entity for the MediPass program in all counties with
3274fewer than two prepaid plans. The contractor may earn an
3275administrative fee, if the fee is less than any savings
3276determined by the reconciliation process pursuant to s.
3277409.912(4)(d)1. This subsection expires October 1, 2014, or upon
3278full implementation of the managed medical assistance program,
3279whichever is sooner.
3280     (19)  Subject to federal approval, the agency shall
3281contract with a single provider service network to function as a
3282third-party administrator and managing entity for the Medically
3283Needy program in all counties. The contractor shall provide care
3284coordination and utilization management in order to achieve more
3285cost-effective services for Medically Needy enrollees. To
3286facilitate the care management functions of the provider service
3287network, enrollment in the network shall be for a continuous 6-
3288month period or until the end of the contract between the
3289provider service network and the agency, whichever is sooner.
3290Beginning the second month after the determination of
3291eligibility, the contractor may collect a monthly premium from
3292each Medically Needy recipient provided the premium does not
3293exceed the enrollee's share of cost as determined by the
3294Department of Children and Family Services. The contractor must
3295provide a 90-day grace period before disenrolling a Medically
3296Needy recipient for failure to pay premiums. The contractor may
3297earn an administrative fee, if the fee is less than any savings
3298determined by the reconciliation process pursuant to s.
3299409.912(4)(d)1. Premium revenue collected from the recipients
3300shall be deducted from the contractor's earned savings. This
3301subsection expires October 1, 2014, or upon full implementation
3302of the managed medical assistance program, whichever is sooner.
3303     Section 18.  Subsection (15) of section 430.04, Florida
3304Statutes, is amended to read:
3305     430.04  Duties and responsibilities of the Department of
3306Elderly Affairs.-The Department of Elderly Affairs shall:
3307     (15)  Administer all Medicaid waivers and programs relating
3308to elders and their appropriations. The waivers include, but are
3309not limited to:
3310     (a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3311established in s. 430.502(7), (8), and (9).
3312     (a)(b)  The Assisted Living for the Frail Elderly Waiver.
3313     (b)(c)  The Aged and Disabled Adult Waiver.
3314     (c)(d)  The Adult Day Health Care Waiver.
3315     (d)(e)  The Consumer-Directed Care Plus Program as defined
3316in s. 409.221.
3317     (e)(f)  The Program of All-inclusive Care for the Elderly.
3318     (f)(g)  The Long-Term Care Community-Based Diversion Pilot
3319Project as described in s. 430.705.
3320     (g)(h)  The Channeling Services Waiver for Frail Elders.
3322The department shall develop a transition plan for recipients
3323receiving services in long-term care Medicaid waivers for elders
3324or disabled adults on the date eligible plans become available
3325in each recipient's region defined in s. 409.981(2) to enroll
3326those recipients in eligible plans. This subsection expires
3327October 1, 2014.
3328     Section 19.  Section 430.2053, Florida Statutes, is amended
3329to read:
3330     430.2053  Aging resource centers.-
3331     (1)  The department, in consultation with the Agency for
3332Health Care Administration and the Department of Children and
3333Family Services, shall develop pilot projects for aging resource
3334centers. By October 31, 2004, the department, in consultation
3335with the agency and the Department of Children and Family
3336Services, shall develop an implementation plan for aging
3337resource centers and submit the plan to the Governor, the
3338President of the Senate, and the Speaker of the House of
3339Representatives. The plan must include qualifications for
3340designation as a center, the functions to be performed by each
3341center, and a process for determining that a current area agency
3342on aging is ready to assume the functions of an aging resource
3344     (2)  Each area agency on aging shall develop, in
3345consultation with the existing community care for the elderly
3346lead agencies within their planning and service areas, a
3347proposal that describes the process the area agency on aging
3348intends to undertake to transition to an aging resource center
3349prior to July 1, 2005, and that describes the area agency's
3350compliance with the requirements of this section. The proposals
3351must be submitted to the department prior to December 31, 2004.
3352The department shall evaluate all proposals for readiness and,
3353prior to March 1, 2005, shall select three area agencies on
3354aging which meet the requirements of this section to begin the
3355transition to aging resource centers. Those area agencies on
3356aging which are not selected to begin the transition to aging
3357resource centers shall, in consultation with the department and
3358the existing community care for the elderly lead agencies within
3359their planning and service areas, amend their proposals as
3360necessary and resubmit them to the department prior to July 1,
33612005. The department may transition additional area agencies to
3362aging resource centers as it determines that area agencies are
3363in compliance with the requirements of this section.
3364     (3)  The Auditor General and the Office of Program Policy
3365Analysis and Government Accountability (OPPAGA) shall jointly
3366review and assess the department's process for determining an
3367area agency's readiness to transition to an aging resource
3369     (a)  The review must, at a minimum, address the
3370appropriateness of the department's criteria for selection of an
3371area agency to transition to an aging resource center, the
3372instruments applied, the degree to which the department
3373accurately determined each area agency's compliance with the
3374readiness criteria, the quality of the technical assistance
3375provided by the department to an area agency in correcting any
3376weaknesses identified in the readiness assessment, and the
3377degree to which each area agency overcame any identified
3379     (b)  Reports of these reviews must be submitted to the
3380appropriate substantive and appropriations committees in the
3381Senate and the House of Representatives on March 1 and September
33821 of each year until full transition to aging resource centers
3383has been accomplished statewide, except that the first report
3384must be submitted by February 1, 2005, and must address all
3385readiness activities undertaken through December 31, 2004. The
3386perspectives of all participants in this review process must be
3387included in each report.
3388     (2)(4)  The purposes of an aging resource center shall be:
3389     (a)  To provide Florida's elders and their families with a
3390locally focused, coordinated approach to integrating information
3391and referral for all available services for elders with the
3392eligibility determination entities for state and federally
3393funded long-term-care services.
3394     (b)  To provide for easier access to long-term-care
3395services by Florida's elders and their families by creating
3396multiple access points to the long-term-care network that flow
3397through one established entity with wide community recognition.
3398     (3)(5)  The duties of an aging resource center are to:
3399     (a)  Develop referral agreements with local community
3400service organizations, such as senior centers, existing elder
3401service providers, volunteer associations, and other similar
3402organizations, to better assist clients who do not need or do
3403not wish to enroll in programs funded by the department or the
3404agency. The referral agreements must also include a protocol,
3405developed and approved by the department, which provides
3406specific actions that an aging resource center and local
3407community service organizations must take when an elder or an
3408elder's representative seeking information on long-term-care
3409services contacts a local community service organization prior
3410to contacting the aging resource center. The protocol shall be
3411designed to ensure that elders and their families are able to
3412access information and services in the most efficient and least
3413cumbersome manner possible.
3414     (b)  Provide an initial screening of all clients who
3415request long-term-care services to determine whether the person
3416would be most appropriately served through any combination of
3417federally funded programs, state-funded programs, locally funded
3418or community volunteer programs, or private funding for
3420     (c)  Determine eligibility for the programs and services
3421listed in subsection (9) (11) for persons residing within the
3422geographic area served by the aging resource center and
3423determine a priority ranking for services which is based upon
3424the potential recipient's frailty level and likelihood of
3425institutional placement without such services.
3426     (d)  Manage the availability of financial resources for the
3427programs and services listed in subsection (9) (11) for persons
3428residing within the geographic area served by the aging resource
3430     (e)  When financial resources become available, refer a
3431client to the most appropriate entity to begin receiving
3432services. The aging resource center shall make referrals to lead
3433agencies for service provision that ensure that individuals who
3434are vulnerable adults in need of services pursuant to s.
3435415.104(3)(b), or who are victims of abuse, neglect, or
3436exploitation in need of immediate services to prevent further
3437harm and are referred by the adult protective services program,
3438are given primary consideration for receiving community-care-
3439for-the-elderly services in compliance with the requirements of
3440s. 430.205(5)(a) and that other referrals for services are in
3441compliance with s. 430.205(5)(b).
3442     (f)  Convene a work group to advise in the planning,
3443implementation, and evaluation of the aging resource center. The
3444work group shall be comprised of representatives of local
3445service providers, Alzheimer's Association chapters, housing
3446authorities, social service organizations, advocacy groups,
3447representatives of clients receiving services through the aging
3448resource center, and any other persons or groups as determined
3449by the department. The aging resource center, in consultation
3450with the work group, must develop annual program improvement
3451plans that shall be submitted to the department for
3452consideration. The department shall review each annual
3453improvement plan and make recommendations on how to implement
3454the components of the plan.
3455     (g)  Enhance the existing area agency on aging in each
3456planning and service area by integrating, either physically or
3457virtually, the staff and services of the area agency on aging
3458with the staff of the department's local CARES Medicaid nursing
3459home preadmission screening unit and a sufficient number of
3460staff from the Department of Children and Family Services'
3461Economic Self-Sufficiency Unit necessary to determine the
3462financial eligibility for all persons age 60 and older residing
3463within the area served by the aging resource center that are
3464seeking Medicaid services, Supplemental Security Income, and
3465food assistance.
3466     (h)  Assist clients who request long-term care services in
3467being evaluated for eligibility for enrollment in the Medicaid
3468long-term care managed care program as eligible plans become
3469available in each of the regions pursuant to s. 409.981(2).
3470     (i)  Provide choice counseling for the Medicaid long-term
3471care managed care program by integrating, either physically or
3472virtually, choice counseling staff and services as eligible
3473plans become available in each of the regions pursuant to s.
3474409.981(2). Pursuant to s. 409.984(1), the agency may contract
3475directly with the aging resource center to provide choice
3476counseling services or may contract with another vendor if the
3477aging resource center does not choose to provide such services.
3478     (j)  Assist Medicaid recipients enrolled in the Medicaid
3479long-term care managed care program with informally resolving
3480grievances with a managed care network and assist Medicaid
3481recipients in accessing the managed care network's formal
3482grievance process as eligible plans become available in each of
3483the regions defined in s. 409.981(2).
3484     (4)(6)  The department shall select the entities to become
3485aging resource centers based on each entity's readiness and
3486ability to perform the duties listed in subsection (3) (5) and
3487the entity's:
3488     (a)  Expertise in the needs of each target population the
3489center proposes to serve and a thorough knowledge of the
3490providers that serve these populations.
3491     (b)  Strong connections to service providers, volunteer
3492agencies, and community institutions.
3493     (c)  Expertise in information and referral activities.
3494     (d)  Knowledge of long-term-care resources, including
3495resources designed to provide services in the least restrictive
3497     (e)  Financial solvency and stability.
3498     (f)  Ability to collect, monitor, and analyze data in a
3499timely and accurate manner, along with systems that meet the
3500department's standards.
3501     (g)  Commitment to adequate staffing by qualified personnel
3502to effectively perform all functions.
3503     (h)  Ability to meet all performance standards established
3504by the department.
3505     (5)(7)  The aging resource center shall have a governing
3506body which shall be the same entity described in s. 20.41(7),
3507and an executive director who may be the same person as
3508described in s. 20.41(7). The governing body shall annually
3509evaluate the performance of the executive director.
3510     (6)(8)  The aging resource center may not be a provider of
3511direct services other than choice counseling as eligible plans
3512become available in each of the regions defined in s.
3513409.981(2), information and referral services, and screening.
3514     (7)(9)  The aging resource center must agree to allow the
3515department to review any financial information the department
3516determines is necessary for monitoring or reporting purposes,
3517including financial relationships.
3518     (8)(10)  The duties and responsibilities of the community
3519care for the elderly lead agencies within each area served by an
3520aging resource center shall be to:
3521     (a)  Develop strong community partnerships to maximize the
3522use of community resources for the purpose of assisting elders
3523to remain in their community settings for as long as it is
3524safely possible.
3525     (b)  Conduct comprehensive assessments of clients that have
3526been determined eligible and develop a care plan consistent with
3527established protocols that ensures that the unique needs of each
3528client are met.
3529     (9)(11)  The services to be administered through the aging
3530resource center shall include those funded by the following
3532     (a)  Community care for the elderly.
3533     (b)  Home care for the elderly.
3534     (c)  Contracted services.
3535     (d)  Alzheimer's disease initiative.
3536     (e)  Aged and disabled adult Medicaid waiver. This
3537paragraph expires October 1, 2013.
3538     (f)  Assisted living for the frail elderly Medicaid waiver.
3539This paragraph expires October 1, 2013.
3540     (g)  Older Americans Act.
3541     (10)(12)  The department shall, prior to designation of an
3542aging resource center, develop by rule operational and quality
3543assurance standards and outcome measures to ensure that clients
3544receiving services through all long-term-care programs
3545administered through an aging resource center are receiving the
3546appropriate care they require and that contractors and
3547subcontractors are adhering to the terms of their contracts and
3548are acting in the best interests of the clients they are
3549serving, consistent with the intent of the Legislature to reduce
3550the use of and cost of nursing home care. The department shall
3551by rule provide operating procedures for aging resource centers,
3552which shall include:
3553     (a)  Minimum standards for financial operation, including
3554audit procedures.
3555     (b)  Procedures for monitoring and sanctioning of service
3557     (c)  Minimum standards for technology utilized by the aging
3558resource center.
3559     (d)  Minimum staff requirements which shall ensure that the
3560aging resource center employs sufficient quality and quantity of
3561staff to adequately meet the needs of the elders residing within
3562the area served by the aging resource center.
3563     (e)  Minimum accessibility standards, including hours of
3565     (f)  Minimum oversight standards for the governing body of
3566the aging resource center to ensure its continuous involvement
3567in, and accountability for, all matters related to the
3568development, implementation, staffing, administration, and
3569operations of the aging resource center.
3570     (g)  Minimum education and experience requirements for
3571executive directors and other executive staff positions of aging
3572resource centers.
3573     (h)  Minimum requirements regarding any executive staff
3574positions that the aging resource center must employ and minimum
3575requirements that a candidate must meet in order to be eligible
3576for appointment to such positions.
3577     (11)(13)  In an area in which the department has designated
3578an area agency on aging as an aging resource center, the
3579department and the agency shall not make payments for the
3580services listed in subsection (9) (11) and the Long-Term Care
3581Community Diversion Project for such persons who were not
3582screened and enrolled through the aging resource center. The
3583department shall cease making payments for recipients in
3584eligible plans as eligible plans become available in each of the
3585regions defined in s. 409.981(2).
3586     (12)(14)  Each aging resource center shall enter into a
3587memorandum of understanding with the department for
3588collaboration with the CARES unit staff. The memorandum of
3589understanding shall outline the staff person responsible for
3590each function and shall provide the staffing levels necessary to
3591carry out the functions of the aging resource center.
3592     (13)(15)  Each aging resource center shall enter into a
3593memorandum of understanding with the Department of Children and
3594Family Services for collaboration with the Economic Self-
3595Sufficiency Unit staff. The memorandum of understanding shall
3596outline which staff persons are responsible for which functions
3597and shall provide the staffing levels necessary to carry out the
3598functions of the aging resource center.
3599     (14)  As eligible plans become available in each of the
3600regions defined in s. 409.981(2), if an aging resource center
3601does not contract with the agency to provide Medicaid long-term
3602care managed care choice counseling pursuant to s. 409.984(1),
3603the aging resource center shall enter into a memorandum of
3604understanding with the agency to coordinate staffing and
3605collaborate with the choice counseling vendor. The memorandum of
3606understanding shall identify the staff responsible for each
3607function and shall provide the staffing levels necessary to
3608carry out the functions of the aging resource center.
3609     (15)(16)  If any of the state activities described in this
3610section are outsourced, either in part or in whole, the contract
3611executing the outsourcing shall mandate that the contractor or
3612its subcontractors shall, either physically or virtually,
3613execute the provisions of the memorandum of understanding
3614instead of the state entity whose function the contractor or
3615subcontractor now performs.
3616     (16)(17)  In order to be eligible to begin transitioning to
3617an aging resource center, an area agency on aging board must
3618ensure that the area agency on aging which it oversees meets all
3619of the minimum requirements set by law and in rule.
3620     (18)  The department shall monitor the three initial
3621projects for aging resource centers and report on the progress
3622of those projects to the Governor, the President of the Senate,
3623and the Speaker of the House of Representatives by June 30,
36242005. The report must include an evaluation of the
3625implementation process.
3626     (17)(19)(a)  Once an aging resource center is operational,
3627the department, in consultation with the agency, may develop
3628capitation rates for any of the programs administered through
3629the aging resource center. Capitation rates for programs shall
3630be based on the historical cost experience of the state in
3631providing those same services to the population age 60 or older
3632residing within each area served by an aging resource center.
3633Each capitated rate may vary by geographic area as determined by
3634the department.
3635     (b)  The department and the agency may determine for each
3636area served by an aging resource center whether it is
3637appropriate, consistent with federal and state laws and
3638regulations, to develop and pay separate capitated rates for
3639each program administered through the aging resource center or
3640to develop and pay capitated rates for service packages which
3641include more than one program or service administered through
3642the aging resource center.
3643     (c)  Once capitation rates have been developed and
3644certified as actuarially sound, the department and the agency
3645may pay service providers the capitated rates for services when
3647     (d)  The department, in consultation with the agency, shall
3648annually reevaluate and recertify the capitation rates,
3649adjusting forward to account for inflation, programmatic
3651     (20)  The department, in consultation with the agency,
3652shall submit to the Governor, the President of the Senate, and
3653the Speaker of the House of Representatives, by December 1,
36542006, a report addressing the feasibility of administering the
3655following services through aging resource centers beginning July
36561, 2007:
3657     (a)  Medicaid nursing home services.
3658     (b)  Medicaid transportation services.
3659     (c)  Medicaid hospice care services.
3660     (d)  Medicaid intermediate care services.
3661     (e)  Medicaid prescribed drug services.
3662     (f)  Medicaid assistive care services.
3663     (g)  Any other long-term-care program or Medicaid service.
3664     (18)(21)  This section shall not be construed to allow an
3665aging resource center to restrict, manage, or impede the local
3666fundraising activities of service providers.
3667     Section 20.  Effective October 1, 2013, sections 430.701,
3668430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3669430.708, and 430.709, Florida Statutes, are repealed.
3670     Section 21.  Sections 409.9301, 409.942, 409.944, 409.945,
3671409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3672as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3673402.87, Florida Statutes, respectively.
3674     Section 22.  Paragraph (a) of subsection (1) of section
3675443.111, Florida Statutes, is amended to read:
3676     443.111  Payment of benefits.-
3677     (1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3678in accordance with rules adopted by the Agency for Workforce
3679Innovation, subject to the following requirements:
3680     (a)  Benefits are payable by mail or electronically.
3681Notwithstanding s. 402.84(4) s. 409.942(4), the agency may
3682develop a system for the payment of benefits by electronic funds
3683transfer, including, but not limited to, debit cards, electronic
3684payment cards, or any other means of electronic payment that the
3685agency deems to be commercially viable or cost-effective.
3686Commodities or services related to the development of such a
3687system shall be procured by competitive solicitation, unless
3688they are purchased from a state term contract pursuant to s.
3689287.056. The agency shall adopt rules necessary to administer
3690the system.
3691     Section 23.  Subsection (4) of section 641.386, Florida
3692Statutes, is amended to read:
3693     641.386  Agent licensing and appointment required;
3695     (4)  All agents and health maintenance organizations shall
3696comply with and be subject to the applicable provisions of ss.
3697641.309 and 409.912(20)(21), and all companies and entities
3698appointing agents shall comply with s. 626.451, when marketing
3699for any health maintenance organization licensed pursuant to
3700this part, including those organizations under contract with the
3701Agency for Health Care Administration to provide health care
3702services to Medicaid recipients or any private entity providing
3703health care services to Medicaid recipients pursuant to a
3704prepaid health plan contract with the Agency for Health Care
3706     Section 24.  Subsections (6) and (7) of section 766.118,
3707Florida Statutes, are renumbered as subsections (7) and (8),
3708respectively, and a new subsection (6) is added to that section,
3709to read:
3710     766.118  Determination of noneconomic damages.-
3713RECIPIENTS.-Notwithstanding subsections (2), (3), (4), and (5),
3714with respect to a cause of action for personal injury or
3715wrongful death arising from medical negligence of practitioners
3716providing services and care to Medicaid recipients as defined in
3717s. 409.901, regardless of the number of such practitioner
3718defendants providing services and care to Medicaid recipients as
3719defined in s. 409.901, noneconomic damages may not exceed
3720$300,000 per claimant. A practitioner providing services and
3721care to Medicaid recipients as defined in s. 409.901 is not
3722liable for more than $200,000 in noneconomic damages, regardless
3723of the number of claimants.
3724     Section 25.  The Agency for Health Care Administration
3725shall develop a plan for implementing s. 409.975(8), Florida
3726Statutes, and shall immediately seek federal approval to
3727implement that subsection. The plan shall include a preliminary
3728calculation of actuarially sound rates and estimated fiscal
3730     Section 26.  Except as otherwise expressly provided in this
3731act, this act shall take effect July 1, 2011, if HB 7107 or
3732similar legislation is adopted in the same legislative session
3733or an extension thereof and becomes law.

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