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. The agency may not make any adjustment to a
646hospital's reimbursement rate more than 5 years after a hospital
647is notified of an audited rate established by the agency. The
648requirement that the agency may not make any adjustment to a
649hospital's reimbursement rate more than 5 years after a hospital
650is notified of an audited rate established by the agency is
651remedial and shall apply to actions by providers involving
652Medicaid claims for hospital services. Hospital rates shall be
653subject to such limits or ceilings as may be established in law
654or described in the agency's hospital reimbursement plan.
655Specific exemptions to the limits or ceilings may be provided in
656the General Appropriations Act. The agency shall adjust a
657hospital's current inpatient per diem rate to reflect the cost
658of serving the Medicaid population at that institution if:
659     1.  The hospital experiences an increase in Medicaid
660caseload by more than 25 percent in any year, primarily
661resulting from the closure of a hospital in the same service
662area occurring after July 1, 1995;
663     2.  The hospital's Medicaid per diem rate is at least 25
664percent below the Medicaid per patient cost for that year; or
665     3.  The hospital is located in a county that has six or
666fewer general acute care hospitals, began offering obstetrical
667services on or after September 1999, and has submitted a request
668in writing to the agency for a rate adjustment after July 1,
6692000, but before September 30, 2000, in which case such
670hospital's Medicaid inpatient per diem rate shall be adjusted to
671cost, effective July 1, 2002.
673By October 1 of each year, the agency must provide estimated
674costs for any adjustment in a hospital inpatient per diem rate
675to the Executive Office of the Governor, the House of
676Representatives General Appropriations Committee, and the Senate
677Appropriations Committee. Before the agency implements a change
678in a hospital's inpatient per diem rate pursuant to this
679paragraph, the Legislature must have specifically appropriated
680sufficient funds in the General Appropriations Act to support
681the increase in cost as estimated by the agency.
682     (g)  The agency shall develop a plan to convert inpatient
683hospital rates to a prospective payment system that categorizes
684each case into diagnosis-related groups (DRG) and assigns a
685payment weight based on the average resources used to treat
686Medicaid patients in that DRG. To the extent possible, the
687agency shall propose an adaptation of an existing prospective
688payment system, such as the one used by Medicare, and shall
689propose such adjustments as are necessary for the Medicaid
690population and to maintain budget neutrality for inpatient
691hospital expenditures. The agency shall submit the Medicaid DRG
692plan, identifying all steps necessary for the transition and any
693costs associated with plan implementation, to the Governor, the
694President of the Senate, and the Speaker of the House of
695Representatives no later than January 1, 2013.
696     Section 9.  Paragraphs (d) and (e) of subsection (5) of
697section 409.907, Florida Statutes, are amended to read:
698     409.907  Medicaid provider agreements.-The agency may make
699payments for medical assistance and related services rendered to
700Medicaid recipients only to an individual or entity who has a
701provider agreement in effect with the agency, who is performing
702services or supplying goods in accordance with federal, state,
703and local law, and who agrees that no person shall, on the
704grounds of handicap, race, color, or national origin, or for any
705other reason, be subjected to discrimination under any program
706or activity for which the provider receives payment from the
708     (5)  The agency:
709     (d)  May enroll entities as Medicare crossover-only
710providers for payment and claims processing purposes only. The
711provider agreement shall:
712     1.  Require that the provider be able to demonstrate to the
713satisfaction of the agency that the provider is an eligible
714Medicare provider and has a current provider agreement in place
715with the Centers for Medicare and Medicaid Services.
716     2.  Require the provider to notify the agency immediately
717in writing upon being suspended or disenrolled as a Medicare
718provider. If the provider does not provide such notification
719within 5 business days after suspension or disenrollment,
720sanctions may be imposed pursuant to this chapter and the
721provider may be required to return funds paid to the provider
722during the period of time that the provider was suspended or
723disenrolled as a Medicare provider.
724     3.  Require the applicant to submit an attestation, as
725approved by the agency, that the provider meets the requirements
726of Florida Medicaid provider enrollment criteria.
727     4.  Require the applicant to submit fingerprints as
728required by the agency.
729     5.3.  Require that all records pertaining to health care
730services provided to each of the provider's recipients be kept
731for a minimum of 6 years. The agreement shall also require that
732records and any information relating to payments claimed by the
733provider for services under the agreement be delivered to the
734agency or the Office of the Attorney General Medicaid Fraud
735Control Unit when requested. If a provider does not provide such
736records and information when requested, sanctions may be imposed
737pursuant to this chapter.
738     6.4.  Disclose that the agreement is for the purposes of
739paying and processing Medicare crossover claims only.
741This paragraph pertains solely to Medicare crossover-only
742providers. In order to become a standard Medicaid provider, the
743requirements of this section and applicable rules must be met.
744This paragraph does not create an entitlement or obligation of
745the agency to enroll all Medicare providers that may be
746considered a Medicare crossover-only provider in the Medicaid
748     (e)  Providers that are required to post a surety bond as
749part of the Medicaid enrollment process are excluded for
750enrollment under paragraph (d) and must complete a full Medicaid
751application. The agency may establish additional criteria to
752promote program integrity.
753     Section 10.  Subsection (10) of section 409.911, Florida
754Statutes, is amended to read:
755     409.911  Disproportionate share program.-Subject to
756specific allocations established within the General
757Appropriations Act and any limitations established pursuant to
758chapter 216, the agency shall distribute, pursuant to this
759section, moneys to hospitals providing a disproportionate share
760of Medicaid or charity care services by making quarterly
761Medicaid payments as required. Notwithstanding the provisions of
762s. 409.915, counties are exempt from contributing toward the
763cost of this special reimbursement for hospitals serving a
764disproportionate share of low-income patients.
765     (10)  The Agency for Health Care Administration shall
766create a Medicaid Low-Income Pool Council by July 1, 2006. The
767Low-Income Pool Council shall consist of 24 members, including 2
768members appointed by the President of the Senate, 2 members
769appointed by the Speaker of the House of Representatives, 3
770representatives of statutory teaching hospitals, 3
771representatives of public hospitals, 3 representatives of
772nonprofit hospitals, 3 representatives of for-profit hospitals,
7732 representatives of rural hospitals, 2 representatives of units
774of local government which contribute funding, 1 representative
775of family practice teaching hospitals, 1 representative of
776federally qualified health centers, 1 representative from the
777Department of Health, and 1 nonvoting representative of the
778Agency for Health Care Administration who shall serve as chair
779of the council. Except for a full-time employee of a public
780entity, an individual who qualifies as a lobbyist under s.
78111.045 or s. 112.3215 may not serve as a member of the council.
782Of the members appointed by the Senate President, only one shall
783be a physician. Of the members appointed by the Speaker of the
784House of Representatives, only one shall be a physician. The
785physician member appointed by the Senate President and the
786physician member appointed by the Speaker of the House of
787Representatives must be physicians who routinely take calls in a
788trauma center, as defined in s. 395.4001, or a hospital
789emergency department. The council shall:
790     (a)  Make recommendations on the financing of the low-
791income pool and the disproportionate share hospital program and
792the distribution of their funds.
793     (b)  Advise the Agency for Health Care Administration on
794the development of the low-income pool plan required by the
795federal Centers for Medicare and Medicaid Services pursuant to
796the Medicaid reform waiver.
797     (c)  Advise the Agency for Health Care Administration on
798the distribution of hospital funds used to adjust inpatient
799hospital rates, rebase rates, or otherwise exempt hospitals from
800reimbursement limits as financed by intergovernmental transfers.
801     (d)  Submit its findings and recommendations to the
802Governor and the Legislature no later than February 1 of each
805This subsection expires October 1, 2014.
806     Section 11.  Subsection (4) of section 409.91195, Florida
807Statutes, is amended to read:
808     409.91195  Medicaid Pharmaceutical and Therapeutics
809Committee.-There is created a Medicaid Pharmaceutical and
810Therapeutics Committee within the agency for the purpose of
811developing a Medicaid preferred drug list.
812     (4)  Upon recommendation of the committee, the agency shall
813adopt a preferred drug list as described in s. 409.912(37)(39).
814To the extent feasible, the committee shall review all drug
815classes included on the preferred drug list every 12 months, and
816may recommend additions to and deletions from the preferred drug
817list, such that the preferred drug list provides for medically
818appropriate drug therapies for Medicaid patients which achieve
819cost savings contained in the General Appropriations Act.
820     Section 12.  Subsection (1) of section 409.91196, Florida
821Statutes, is amended to read:
822     409.91196  Supplemental rebate agreements; public records
823and public meetings exemption.-
824     (1)  The rebate amount, percent of rebate, manufacturer's
825pricing, and supplemental rebate, and other trade secrets as
826defined in s. 688.002 that the agency has identified for use in
827negotiations, held by the Agency for Health Care Administration
828under s. 409.912(37)(39)(a)7. are confidential and exempt from
829s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
830     Section 13.  Section 409.912, Florida Statutes, is amended
831to read:
832     409.912  Cost-effective purchasing of health care.-The
833agency shall purchase goods and services for Medicaid recipients
834in the most cost-effective manner consistent with the delivery
835of quality medical care. To ensure that medical services are
836effectively utilized, the agency may, in any case, require a
837confirmation or second physician's opinion of the correct
838diagnosis for purposes of authorizing future services under the
839Medicaid program. This section does not restrict access to
840emergency services or poststabilization care services as defined
841in 42 C.F.R. part 438.114. Such confirmation or second opinion
842shall be rendered in a manner approved by the agency. The agency
843shall maximize the use of prepaid per capita and prepaid
844aggregate fixed-sum basis services when appropriate and other
845alternative service delivery and reimbursement methodologies,
846including competitive bidding pursuant to s. 287.057, designed
847to facilitate the cost-effective purchase of a case-managed
848continuum of care. The agency shall also require providers to
849minimize the exposure of recipients to the need for acute
850inpatient, custodial, and other institutional care and the
851inappropriate or unnecessary use of high-cost services. The
852agency shall contract with a vendor to monitor and evaluate the
853clinical practice patterns of providers in order to identify
854trends that are outside the normal practice patterns of a
855provider's professional peers or the national guidelines of a
856provider's professional association. The vendor must be able to
857provide information and counseling to a provider whose practice
858patterns are outside the norms, in consultation with the agency,
859to improve patient care and reduce inappropriate utilization.
860The agency may mandate prior authorization, drug therapy
861management, or disease management participation for certain
862populations of Medicaid beneficiaries, certain drug classes, or
863particular drugs to prevent fraud, abuse, overuse, and possible
864dangerous drug interactions. The Pharmaceutical and Therapeutics
865Committee shall make recommendations to the agency on drugs for
866which prior authorization is required. The agency shall inform
867the Pharmaceutical and Therapeutics Committee of its decisions
868regarding drugs subject to prior authorization. The agency is
869authorized to limit the entities it contracts with or enrolls as
870Medicaid providers by developing a provider network through
871provider credentialing. The agency may competitively bid single-
872source-provider contracts if procurement of goods or services
873results in demonstrated cost savings to the state without
874limiting access to care. The agency may limit its network based
875on the assessment of beneficiary access to care, provider
876availability, provider quality standards, time and distance
877standards for access to care, the cultural competence of the
878provider network, demographic characteristics of Medicaid
879beneficiaries, practice and provider-to-beneficiary standards,
880appointment wait times, beneficiary use of services, provider
881turnover, provider profiling, provider licensure history,
882previous program integrity investigations and findings, peer
883review, provider Medicaid policy and billing compliance records,
884clinical and medical record audits, and other factors. Providers
885are shall not be entitled to enrollment in the Medicaid provider
886network. The agency shall determine instances in which allowing
887Medicaid beneficiaries to purchase durable medical equipment and
888other goods is less expensive to the Medicaid program than long-
889term rental of the equipment or goods. The agency may establish
890rules to facilitate purchases in lieu of long-term rentals in
891order to protect against fraud and abuse in the Medicaid program
892as defined in s. 409.913. The agency may seek federal waivers
893necessary to administer these policies.
894     (1)  The agency shall work with the Department of Children
895and Family Services to ensure access of children and families in
896the child protection system to needed and appropriate mental
897health and substance abuse services. This subsection expires
898October 1, 2014.
899     (2)  The agency may enter into agreements with appropriate
900agents of other state agencies or of any agency of the Federal
901Government and accept such duties in respect to social welfare
902or public aid as may be necessary to implement the provisions of
903Title XIX of the Social Security Act and ss. 409.901-409.920.
904This subsection expires October 1, 2016.
905     (3)  The agency may contract with health maintenance
906organizations certified pursuant to part I of chapter 641 for
907the provision of services to recipients. This subsection expires
908October 1, 2014.
909     (4)  The agency may contract with:
910     (a)  An entity that provides no prepaid health care
911services other than Medicaid services under contract with the
912agency and which is owned and operated by a county, county
913health department, or county-owned and operated hospital to
914provide health care services on a prepaid or fixed-sum basis to
915recipients, which entity may provide such prepaid services
916either directly or through arrangements with other providers.
917Such prepaid health care services entities must be licensed
918under parts I and III of chapter 641. An entity recognized under
919this paragraph which demonstrates to the satisfaction of the
920Office of Insurance Regulation of the Financial Services
921Commission that it is backed by the full faith and credit of the
922county in which it is located may be exempted from s. 641.225.
923This paragraph expires October 1, 2014.
924     (b)  An entity that is providing comprehensive behavioral
925health care services to certain Medicaid recipients through a
926capitated, prepaid arrangement pursuant to the federal waiver
927provided for by s. 409.905(5). Such entity must be licensed
928under chapter 624, chapter 636, or chapter 641, or authorized
929under paragraph (c) or paragraph (d), and must possess the
930clinical systems and operational competence to manage risk and
931provide comprehensive behavioral health care to Medicaid
932recipients. As used in this paragraph, the term "comprehensive
933behavioral health care services" means covered mental health and
934substance abuse treatment services that are available to
935Medicaid recipients. The secretary of the Department of Children
936and Family Services shall approve provisions of procurements
937related to children in the department's care or custody before
938enrolling such children in a prepaid behavioral health plan. Any
939contract awarded under this paragraph must be competitively
940procured. In developing the behavioral health care prepaid plan
941procurement document, the agency shall ensure that the
942procurement document requires the contractor to develop and
943implement a plan to ensure compliance with s. 394.4574 related
944to services provided to residents of licensed assisted living
945facilities that hold a limited mental health license. Except as
946provided in subparagraph 5. 8., and except in counties where the
947Medicaid managed care pilot program is authorized pursuant to s.
948409.91211, the agency shall seek federal approval to contract
949with a single entity meeting these requirements to provide
950comprehensive behavioral health care services to all Medicaid
951recipients not enrolled in a Medicaid managed care plan
952authorized under s. 409.91211, a provider service network
953authorized under paragraph (d), or a Medicaid health maintenance
954organization in an AHCA area. In an AHCA area where the Medicaid
955managed care pilot program is authorized pursuant to s.
956409.91211 in one or more counties, the agency may procure a
957contract with a single entity to serve the remaining counties as
958an AHCA area or the remaining counties may be included with an
959adjacent AHCA area and are subject to this paragraph. Each
960entity must offer a sufficient choice of providers in its
961network to ensure recipient access to care and the opportunity
962to select a provider with whom they are satisfied. The network
963shall include all public mental health hospitals. To ensure
964unimpaired access to behavioral health care services by Medicaid
965recipients, all contracts issued pursuant to this paragraph must
966require 80 percent of the capitation paid to the managed care
967plan, including health maintenance organizations and capitated
968provider service networks, to be expended for the provision of
969behavioral health care services. If the managed care plan
970expends less than 80 percent of the capitation paid for the
971provision of behavioral health care services, the difference
972shall be returned to the agency. The agency shall provide the
973plan with a certification letter indicating the amount of
974capitation paid during each calendar year for behavioral health
975care services pursuant to this section. The agency may reimburse
976for substance abuse treatment services on a fee-for-service
977basis until the agency finds that adequate funds are available
978for capitated, prepaid arrangements.
979     1.  By January 1, 2001, The agency shall modify the
980contracts with the entities providing comprehensive inpatient
981and outpatient mental health care services to Medicaid
982recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
983Counties, to include substance abuse treatment services.
984     2.  By July 1, 2003, the agency and the Department of
985Children and Family Services shall execute a written agreement
986that requires collaboration and joint development of all policy,
987budgets, procurement documents, contracts, and monitoring plans
988that have an impact on the state and Medicaid community mental
989health and targeted case management programs.
990     2.3.  Except as provided in subparagraph 5. 8., by July 1,
9912006, the agency and the Department of Children and Family
992Services shall contract with managed care entities in each AHCA
993area except area 6 or arrange to provide comprehensive inpatient
994and outpatient mental health and substance abuse services
995through capitated prepaid arrangements to all Medicaid
996recipients who are eligible to participate in such plans under
997federal law and regulation. In AHCA areas where eligible
998individuals number less than 150,000, the agency shall contract
999with a single managed care plan to provide comprehensive
1000behavioral health services to all recipients who are not
1001enrolled in a Medicaid health maintenance organization, a
1002provider service network authorized under paragraph (d), or a
1003Medicaid capitated managed care plan authorized under s.
1004409.91211. The agency may contract with more than one
1005comprehensive behavioral health provider to provide care to
1006recipients who are not enrolled in a Medicaid capitated managed
1007care plan authorized under s. 409.91211, a provider service
1008network authorized under paragraph (d), or a Medicaid health
1009maintenance organization in AHCA areas where the eligible
1010population exceeds 150,000. In an AHCA area where the Medicaid
1011managed care pilot program is authorized pursuant to s.
1012409.91211 in one or more counties, the agency may procure a
1013contract with a single entity to serve the remaining counties as
1014an AHCA area or the remaining counties may be included with an
1015adjacent AHCA area and shall be subject to this paragraph.
1016Contracts for comprehensive behavioral health providers awarded
1017pursuant to this section shall be competitively procured. Both
1018for-profit and not-for-profit corporations are eligible to
1019compete. Managed care plans contracting with the agency under
1020subsection (3) or paragraph (d), shall provide and receive
1021payment for the same comprehensive behavioral health benefits as
1022provided in AHCA rules, including handbooks incorporated by
1023reference. In AHCA area 11, the agency shall contract with at
1024least two comprehensive behavioral health care providers to
1025provide behavioral health care to recipients in that area who
1026are enrolled in, or assigned to, the MediPass program. One of
1027the behavioral health care contracts must be with the existing
1028provider service network pilot project, as described in
1029paragraph (d), for the purpose of demonstrating the cost-
1030effectiveness of the provision of quality mental health services
1031through a public hospital-operated managed care model. Payment
1032shall be at an agreed-upon capitated rate to ensure cost
1033savings. Of the recipients in area 11 who are assigned to
1034MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1035MediPass-enrolled recipients shall be assigned to the existing
1036provider service network in area 11 for their behavioral care.
1037     4.  By October 1, 2003, the agency and the department shall
1038submit a plan to the Governor, the President of the Senate, and
1039the Speaker of the House of Representatives which provides for
1040the full implementation of capitated prepaid behavioral health
1041care in all areas of the state.
1042     a.  Implementation shall begin in 2003 in those AHCA areas
1043of the state where the agency is able to establish sufficient
1044capitation rates.
1045     b.  If the agency determines that the proposed capitation
1046rate in any area is insufficient to provide appropriate
1047services, the agency may adjust the capitation rate to ensure
1048that care will be available. The agency and the department may
1049use existing general revenue to address any additional required
1050match but may not over-obligate existing funds on an annualized
1052     c.  Subject to any limitations provided in the General
1053Appropriations Act, the agency, in compliance with appropriate
1054federal authorization, shall develop policies and procedures
1055that allow for certification of local and state funds.
1056     3.5.  Children residing in a statewide inpatient
1057psychiatric program, or in a Department of Juvenile Justice or a
1058Department of Children and Family Services residential program
1059approved as a Medicaid behavioral health overlay services
1060provider may not be included in a behavioral health care prepaid
1061health plan or any other Medicaid managed care plan pursuant to
1062this paragraph.
1063     6.  In converting to a prepaid system of delivery, the
1064agency shall in its procurement document require an entity
1065providing only comprehensive behavioral health care services to
1066prevent the displacement of indigent care patients by enrollees
1067in the Medicaid prepaid health plan providing behavioral health
1068care services from facilities receiving state funding to provide
1069indigent behavioral health care, to facilities licensed under
1070chapter 395 which do not receive state funding for indigent
1071behavioral health care, or reimburse the unsubsidized facility
1072for the cost of behavioral health care provided to the displaced
1073indigent care patient.
1074     4.7.  Traditional community mental health providers under
1075contract with the Department of Children and Family Services
1076pursuant to part IV of chapter 394, child welfare providers
1077under contract with the Department of Children and Family
1078Services in areas 1 and 6, and inpatient mental health providers
1079licensed pursuant to chapter 395 must be offered an opportunity
1080to accept or decline a contract to participate in any provider
1081network for prepaid behavioral health services.
1082     5.8.  All Medicaid-eligible children, except children in
1083area 1 and children in Highlands County, Hardee County, Polk
1084County, or Manatee County of area 6, that are open for child
1085welfare services in the HomeSafeNet system, shall receive their
1086behavioral health care services through a specialty prepaid plan
1087operated by community-based lead agencies through a single
1088agency or formal agreements among several agencies. The
1089specialty prepaid plan must result in savings to the state
1090comparable to savings achieved in other Medicaid managed care
1091and prepaid programs. Such plan must provide mechanisms to
1092maximize state and local revenues. The specialty prepaid plan
1093shall be developed by the agency and the Department of Children
1094and Family Services. The agency may seek federal waivers to
1095implement this initiative. Medicaid-eligible children whose
1096cases are open for child welfare services in the HomeSafeNet
1097system and who reside in AHCA area 10 are exempt from the
1098specialty prepaid plan upon the development of a service
1099delivery mechanism for children who reside in area 10 as
1100specified in s. 409.91211(3)(dd).
1102This paragraph expires October 1, 2014.
1103     (c)  A federally qualified health center or an entity owned
1104by one or more federally qualified health centers or an entity
1105owned by other migrant and community health centers receiving
1106non-Medicaid financial support from the Federal Government to
1107provide health care services on a prepaid or fixed-sum basis to
1108recipients. A federally qualified health center or an entity
1109that is owned by one or more federally qualified health centers
1110and is reimbursed by the agency on a prepaid basis is exempt
1111from parts I and III of chapter 641, but must comply with the
1112solvency requirements in s. 641.2261(2) and meet the appropriate
1113requirements governing financial reserve, quality assurance, and
1114patients' rights established by the agency. This paragraph
1115expires October 1, 2014.
1116     (d)1.  A provider service network may be reimbursed on a
1117fee-for-service or prepaid basis. Prepaid provider service
1118networks shall receive per-member, per-month payments. A
1119provider service network that does not choose to be a prepaid
1120plan shall receive fee-for-service rates with a shared savings
1121settlement. The fee-for-service option shall be available to a
1122provider service network only for the first 3 years of the  
1123plan's operation or until the contract year beginning October 1,
11242012, whichever is sooner. The agency shall annually conduct
1125cost reconciliations to determine the amount of cost savings
1126achieved by fee-for-service provider service networks for the
1127dates of service in the period being reconciled. Only payments
1128for covered services for dates of service within the
1129reconciliation period and paid within 6 months after the last
1130date of service in the reconciliation period shall be included.
1131The agency shall perform the necessary adjustments for the
1132inclusion of claims incurred but not reported within the
1133reconciliation for claims that could be received and paid by the
1134agency after the 6-month claims processing time lag. The agency
1135shall provide the results of the reconciliations to the fee-for-
1136service provider service networks within 45 days after the end
1137of the reconciliation period. The fee-for-service provider
1138service networks shall review and provide written comments or a
1139letter of concurrence to the agency within 45 days after receipt
1140of the reconciliation results. This reconciliation shall be
1141considered final.
1142     2.  A provider service network which is reimbursed by the
1143agency on a prepaid basis shall be exempt from parts I and III
1144of chapter 641, but must comply with the solvency requirements
1145in s. 641.2261(2) and meet appropriate financial reserve,
1146quality assurance, and patient rights requirements as
1147established by the agency.
1148     3.  Medicaid recipients assigned to a provider service
1149network shall be chosen equally from those who would otherwise
1150have been assigned to prepaid plans and MediPass. The agency is
1151authorized to seek federal Medicaid waivers as necessary to
1152implement the provisions of this section. This subparagraph
1153expires October 1, 2014. Any contract previously awarded to a
1154provider service network operated by a hospital pursuant to this
1155subsection shall remain in effect for a period of 3 years
1156following the current contract expiration date, regardless of
1157any contractual provisions to the contrary.
1158     4.  A provider service network is a network established or
1159organized and operated by a health care provider, or group of
1160affiliated health care providers, including minority physician
1161networks and emergency room diversion programs that meet the
1162requirements of s. 409.91211, which provides a substantial
1163proportion of the health care items and services under a
1164contract directly through the provider or affiliated group of
1165providers and may make arrangements with physicians or other
1166health care professionals, health care institutions, or any
1167combination of such individuals or institutions to assume all or
1168part of the financial risk on a prospective basis for the
1169provision of basic health services by the physicians, by other
1170health professionals, or through the institutions. The health
1171care providers must have a controlling interest in the governing
1172body of the provider service network organization.
1173     (e)  An entity that provides only comprehensive behavioral
1174health care services to certain Medicaid recipients through an
1175administrative services organization agreement. Such an entity
1176must possess the clinical systems and operational competence to
1177provide comprehensive health care to Medicaid recipients. As
1178used in this paragraph, the term "comprehensive behavioral
1179health care services" means covered mental health and substance
1180abuse treatment services that are available to Medicaid
1181recipients. Any contract awarded under this paragraph must be
1182competitively procured. The agency must ensure that Medicaid
1183recipients have available the choice of at least two managed
1184care plans for their behavioral health care services. This
1185paragraph expires October 1, 2014.
1186     (f)  An entity that provides in-home physician services to
1187test the cost-effectiveness of enhanced home-based medical care
1188to Medicaid recipients with degenerative neurological diseases
1189and other diseases or disabling conditions associated with high
1190costs to Medicaid. The program shall be designed to serve very
1191disabled persons and to reduce Medicaid reimbursed costs for
1192inpatient, outpatient, and emergency department services. The
1193agency shall contract with vendors on a risk-sharing basis.
1194     (g)  Children's provider networks that provide care
1195coordination and care management for Medicaid-eligible pediatric
1196patients, primary care, authorization of specialty care, and
1197other urgent and emergency care through organized providers
1198designed to service Medicaid eligibles under age 18 and
1199pediatric emergency departments' diversion programs. The
1200networks shall provide after-hour operations, including evening
1201and weekend hours, to promote, when appropriate, the use of the
1202children's networks rather than hospital emergency departments.
1203     (f)(h)  An entity authorized in s. 430.205 to contract with
1204the agency and the Department of Elderly Affairs to provide
1205health care and social services on a prepaid or fixed-sum basis
1206to elderly recipients. Such prepaid health care services
1207entities are exempt from the provisions of part I of chapter 641
1208for the first 3 years of operation. An entity recognized under
1209this paragraph that demonstrates to the satisfaction of the
1210Office of Insurance Regulation that it is backed by the full
1211faith and credit of one or more counties in which it operates
1212may be exempted from s. 641.225. This paragraph expires October
12131, 2013.
1214     (g)(i)  A Children's Medical Services Network, as defined
1215in s. 391.021. This paragraph expires October 1, 2014.
1216     (5)  The Agency for Health Care Administration, in
1217partnership with the Department of Elderly Affairs, shall create
1218an integrated, fixed-payment delivery program for Medicaid
1219recipients who are 60 years of age or older or dually eligible
1220for Medicare and Medicaid. The Agency for Health Care
1221Administration shall implement the integrated program initially
1222on a pilot basis in two areas of the state. The pilot areas
1223shall be Area 7 and Area 11 of the Agency for Health Care
1224Administration. Enrollment in the pilot areas shall be on a
1225voluntary basis and in accordance with approved federal waivers
1226and this section. The agency and its program contractors and
1227providers shall not enroll any individual in the integrated
1228program because the individual or the person legally responsible
1229for the individual fails to choose to enroll in the integrated
1230program. Enrollment in the integrated program shall be
1231exclusively by affirmative choice of the eligible individual or
1232by the person legally responsible for the individual. The
1233integrated program must transfer all Medicaid services for
1234eligible elderly individuals who choose to participate into an
1235integrated-care management model designed to serve Medicaid
1236recipients in the community. The integrated program must combine
1237all funding for Medicaid services provided to individuals who
1238are 60 years of age or older or dually eligible for Medicare and
1239Medicaid into the integrated program, including funds for
1240Medicaid home and community-based waiver services; all Medicaid
1241services authorized in ss. 409.905 and 409.906, excluding funds
1242for Medicaid nursing home services unless the agency is able to
1243demonstrate how the integration of the funds will improve
1244coordinated care for these services in a less costly manner; and
1245Medicare coinsurance and deductibles for persons dually eligible
1246for Medicaid and Medicare as prescribed in s. 409.908(13).
1247     (a)  Individuals who are 60 years of age or older or dually
1248eligible for Medicare and Medicaid and enrolled in the
1249developmental disabilities waiver program, the family and
1250supported-living waiver program, the project AIDS care waiver
1251program, the traumatic brain injury and spinal cord injury
1252waiver program, the consumer-directed care waiver program, and
1253the program of all-inclusive care for the elderly program, and
1254residents of institutional care facilities for the
1255developmentally disabled, must be excluded from the integrated
1257     (b)  Managed care entities who meet or exceed the agency's
1258minimum standards are eligible to operate the integrated
1259program. Entities eligible to participate include managed care
1260organizations licensed under chapter 641, including entities
1261eligible to participate in the nursing home diversion program,
1262other qualified providers as defined in s. 430.703(7), community
1263care for the elderly lead agencies, and other state-certified
1264community service networks that meet comparable standards as
1265defined by the agency, in consultation with the Department of
1266Elderly Affairs and the Office of Insurance Regulation, to be
1267financially solvent and able to take on financial risk for
1268managed care. Community service networks that are certified
1269pursuant to the comparable standards defined by the agency are
1270not required to be licensed under chapter 641. Managed care
1271entities who operate the integrated program shall be subject to
1272s. 408.7056. Eligible entities shall choose to serve enrollees
1273who are dually eligible for Medicare and Medicaid, enrollees who
1274are 60 years of age or older, or both.
1275     (c)  The agency must ensure that the capitation-rate-
1276setting methodology for the integrated program is actuarially
1277sound and reflects the intent to provide quality care in the
1278least restrictive setting. The agency must also require
1279integrated-program providers to develop a credentialing system
1280for service providers and to contract with all Gold Seal nursing
1281homes, where feasible, and exclude, where feasible, chronically
1282poor-performing facilities and providers as defined by the
1283agency. The integrated program must develop and maintain an
1284informal provider grievance system that addresses provider
1285payment and contract problems. The agency shall also establish a
1286formal grievance system to address those issues that were not
1287resolved through the informal grievance system. The integrated
1288program must provide that if the recipient resides in a
1289noncontracted residential facility licensed under chapter 400 or
1290chapter 429 at the time of enrollment in the integrated program,
1291the recipient must be permitted to continue to reside in the
1292noncontracted facility as long as the recipient desires. The
1293integrated program must also provide that, in the absence of a
1294contract between the integrated-program provider and the
1295residential facility licensed under chapter 400 or chapter 429,
1296current Medicaid rates must prevail. The integrated-program
1297provider must ensure that electronic nursing home claims that
1298contain sufficient information for processing are paid within 10
1299business days after receipt. Alternately, the integrated-program
1300provider may establish a capitated payment mechanism to
1301prospectively pay nursing homes at the beginning of each month.
1302The agency and the Department of Elderly Affairs must jointly
1303develop procedures to manage the services provided through the
1304integrated program in order to ensure quality and recipient
1306     (d)  The Office of Program Policy Analysis and Government
1307Accountability, in consultation with the Auditor General, shall
1308comprehensively evaluate the pilot project for the integrated,
1309fixed-payment delivery program for Medicaid recipients created
1310under this subsection. The evaluation shall begin as soon as
1311Medicaid recipients are enrolled in the managed care pilot
1312program plans and shall continue for 24 months thereafter. The
1313evaluation must include assessments of each managed care plan in
1314the integrated program with regard to cost savings; consumer
1315education, choice, and access to services; coordination of care;
1316and quality of care. The evaluation must describe administrative
1317or legal barriers to the implementation and operation of the
1318pilot program and include recommendations regarding statewide
1319expansion of the pilot program. The office shall submit its
1320evaluation report to the Governor, the President of the Senate,
1321and the Speaker of the House of Representatives no later than
1322December 31, 2009.
1323     (e)  The agency may seek federal waivers or Medicaid state
1324plan amendments and adopt rules as necessary to administer the
1325integrated program. The agency may implement the approved
1326federal waivers and other provisions as specified in this
1328     (f)  The implementation of the integrated, fixed-payment
1329delivery program created under this subsection is subject to an
1330appropriation in the General Appropriations Act.
1331     (5)(6)  The agency may contract with any public or private
1332entity otherwise authorized by this section on a prepaid or
1333fixed-sum basis for the provision of health care services to
1334recipients. An entity may provide prepaid services to
1335recipients, either directly or through arrangements with other
1336entities, if each entity involved in providing services:
1337     (a)  Is organized primarily for the purpose of providing
1338health care or other services of the type regularly offered to
1339Medicaid recipients;
1340     (b)  Ensures that services meet the standards set by the
1341agency for quality, appropriateness, and timeliness;
1342     (c)  Makes provisions satisfactory to the agency for
1343insolvency protection and ensures that neither enrolled Medicaid
1344recipients nor the agency will be liable for the debts of the
1346     (d)  Submits to the agency, if a private entity, a
1347financial plan that the agency finds to be fiscally sound and
1348that provides for working capital in the form of cash or
1349equivalent liquid assets excluding revenues from Medicaid
1350premium payments equal to at least the first 3 months of
1351operating expenses or $200,000, whichever is greater;
1352     (e)  Furnishes evidence satisfactory to the agency of
1353adequate liability insurance coverage or an adequate plan of
1354self-insurance to respond to claims for injuries arising out of
1355the furnishing of health care;
1356     (f)  Provides, through contract or otherwise, for periodic
1357review of its medical facilities and services, as required by
1358the agency; and
1359     (g)  Provides organizational, operational, financial, and
1360other information required by the agency.
1362This subsection expires October 1, 2014.
1363     (6)(7)  The agency may contract on a prepaid or fixed-sum
1364basis with any health insurer that:
1365     (a)  Pays for health care services provided to enrolled
1366Medicaid recipients in exchange for a premium payment paid by
1367the agency;
1368     (b)  Assumes the underwriting risk; and
1369     (c)  Is organized and licensed under applicable provisions
1370of the Florida Insurance Code and is currently in good standing
1371with the Office of Insurance Regulation.
1373This subsection expires October 1, 2014.
1374     (7)(8)(a)  The agency may contract on a prepaid or fixed-
1375sum basis with an exclusive provider organization to provide
1376health care services to Medicaid recipients provided that the
1377exclusive provider organization meets applicable managed care
1378plan requirements in this section, ss. 409.9122, 409.9123,
1379409.9128, and 627.6472, and other applicable provisions of law.
1380This subsection expires October 1, 2014.
1381     (b)  For a period of no longer than 24 months after the
1382effective date of this paragraph, when a member of an exclusive
1383provider organization that is contracted by the agency to
1384provide health care services to Medicaid recipients in rural
1385areas without a health maintenance organization obtains services
1386from a provider that participates in the Medicaid program in
1387this state, the provider shall be paid in accordance with the
1388appropriate fee schedule for services provided to eligible
1389Medicaid recipients. The agency may seek waiver authority to
1390implement this paragraph.
1391     (8)(9)  The Agency for Health Care Administration may
1392provide cost-effective purchasing of chiropractic services on a
1393fee-for-service basis to Medicaid recipients through
1394arrangements with a statewide chiropractic preferred provider
1395organization incorporated in this state as a not-for-profit
1396corporation. The agency shall ensure that the benefit limits and
1397prior authorization requirements in the current Medicaid program
1398shall apply to the services provided by the chiropractic
1399preferred provider organization. This subsection expires October
14001, 2014.
1401     (9)(10)  The agency shall not contract on a prepaid or
1402fixed-sum basis for Medicaid services with an entity which knows
1403or reasonably should know that any officer, director, agent,
1404managing employee, or owner of stock or beneficial interest in
1405excess of 5 percent common or preferred stock, or the entity
1406itself, has been found guilty of, regardless of adjudication, or
1407entered a plea of nolo contendere, or guilty, to:
1408     (a)  Fraud;
1409     (b)  Violation of federal or state antitrust statutes,
1410including those proscribing price fixing between competitors and
1411the allocation of customers among competitors;
1412     (c)  Commission of a felony involving embezzlement, theft,
1413forgery, income tax evasion, bribery, falsification or
1414destruction of records, making false statements, receiving
1415stolen property, making false claims, or obstruction of justice;
1417     (d)  Any crime in any jurisdiction which directly relates
1418to the provision of health services on a prepaid or fixed-sum
1421This subsection expires October 1, 2014.
1422     (10)(11)  The agency, after notifying the Legislature, may
1423apply for waivers of applicable federal laws and regulations as
1424necessary to implement more appropriate systems of health care
1425for Medicaid recipients and reduce the cost of the Medicaid
1426program to the state and federal governments and shall implement
1427such programs, after legislative approval, within a reasonable
1428period of time after federal approval. These programs must be
1429designed primarily to reduce the need for inpatient care,
1430custodial care and other long-term or institutional care, and
1431other high-cost services. Prior to seeking legislative approval
1432of such a waiver as authorized by this subsection, the agency
1433shall provide notice and an opportunity for public comment.
1434Notice shall be provided to all persons who have made requests
1435of the agency for advance notice and shall be published in the
1436Florida Administrative Weekly not less than 28 days prior to the
1437intended action. This subsection expires October 1, 2016.
1438     (11)(12)  The agency shall establish a postpayment
1439utilization control program designed to identify recipients who
1440may inappropriately overuse or underuse Medicaid services and
1441shall provide methods to correct such misuse. This subsection
1442expires October 1, 2014.
1443     (12)(13)  The agency shall develop and provide coordinated
1444systems of care for Medicaid recipients and may contract with
1445public or private entities to develop and administer such
1446systems of care among public and private health care providers
1447in a given geographic area. This subsection expires October 1,
1449     (13)(14)(a)  The agency shall operate or contract for the
1450operation of utilization management and incentive systems
1451designed to encourage cost-effective use of services and to
1452eliminate services that are medically unnecessary. The agency
1453shall track Medicaid provider prescription and billing patterns
1454and evaluate them against Medicaid medical necessity criteria
1455and coverage and limitation guidelines adopted by rule. Medical
1456necessity determination requires that service be consistent with
1457symptoms or confirmed diagnosis of illness or injury under
1458treatment and not in excess of the patient's needs. The agency
1459shall conduct reviews of provider exceptions to peer group norms
1460and shall, using statistical methodologies, provider profiling,
1461and analysis of billing patterns, detect and investigate
1462abnormal or unusual increases in billing or payment of claims
1463for Medicaid services and medically unnecessary provision of
1464services. Providers that demonstrate a pattern of submitting
1465claims for medically unnecessary services shall be referred to
1466the Medicaid program integrity unit for investigation. In its
1467annual report, required in s. 409.913, the agency shall report
1468on its efforts to control overutilization as described in this
1469subsection paragraph. This subsection expires October 1, 2014.
1470     (b)  The agency shall develop a procedure for determining
1471whether health care providers and service vendors can provide
1472the Medicaid program using a business case that demonstrates
1473whether a particular good or service can offset the cost of
1474providing the good or service in an alternative setting or
1475through other means and therefore should receive a higher
1476reimbursement. The business case must include, but need not be
1477limited to:
1478     1.  A detailed description of the good or service to be
1479provided, a description and analysis of the agency's current
1480performance of the service, and a rationale documenting how
1481providing the service in an alternative setting would be in the
1482best interest of the state, the agency, and its clients.
1483     2.  A cost-benefit analysis documenting the estimated
1484specific direct and indirect costs, savings, performance
1485improvements, risks, and qualitative and quantitative benefits
1486involved in or resulting from providing the service. The cost-
1487benefit analysis must include a detailed plan and timeline
1488identifying all actions that must be implemented to realize
1489expected benefits. The Secretary of Health Care Administration
1490shall verify that all costs, savings, and benefits are valid and
1492     (c)  If the agency determines that the increased
1493reimbursement is cost-effective, the agency shall recommend a
1494change in the reimbursement schedule for that particular good or
1495service. If, within 12 months after implementing any rate change
1496under this procedure, the agency determines that costs were not
1497offset by the increased reimbursement schedule, the agency may
1498revert to the former reimbursement schedule for the particular
1499good or service.
1500     (14)(15)(a)  The agency shall operate the Comprehensive
1501Assessment and Review for Long-Term Care Services (CARES)
1502nursing facility preadmission screening program to ensure that
1503Medicaid payment for nursing facility care is made only for
1504individuals whose conditions require such care and to ensure
1505that long-term care services are provided in the setting most
1506appropriate to the needs of the person and in the most
1507economical manner possible. The CARES program shall also ensure
1508that individuals participating in Medicaid home and community-
1509based waiver programs meet criteria for those programs,
1510consistent with approved federal waivers.
1511     (b)  The agency shall operate the CARES program through an
1512interagency agreement with the Department of Elderly Affairs.
1513The agency, in consultation with the Department of Elderly
1514Affairs, may contract for any function or activity of the CARES
1515program, including any function or activity required by 42
1516C.F.R. part 483.20, relating to preadmission screening and
1517resident review.
1518     (c)  Prior to making payment for nursing facility services
1519for a Medicaid recipient, the agency must verify that the
1520nursing facility preadmission screening program has determined
1521that the individual requires nursing facility care and that the
1522individual cannot be safely served in community-based programs.
1523The nursing facility preadmission screening program shall refer
1524a Medicaid recipient to a community-based program if the
1525individual could be safely served at a lower cost and the
1526recipient chooses to participate in such program. For
1527individuals whose nursing home stay is initially funded by
1528Medicare and Medicare coverage is being terminated for lack of
1529progress towards rehabilitation, CARES staff shall consult with
1530the person making the determination of progress toward
1531rehabilitation to ensure that the recipient is not being
1532inappropriately disqualified from Medicare coverage. If, in
1533their professional judgment, CARES staff believes that a
1534Medicare beneficiary is still making progress toward
1535rehabilitation, they may assist the Medicare beneficiary with an
1536appeal of the disqualification from Medicare coverage. The use
1537of CARES teams to review Medicare denials for coverage under
1538this section is authorized only if it is determined that such
1539reviews qualify for federal matching funds through Medicaid. The
1540agency shall seek or amend federal waivers as necessary to
1541implement this section.
1542     (d)  For the purpose of initiating immediate prescreening
1543and diversion assistance for individuals residing in nursing
1544homes and in order to make families aware of alternative long-
1545term care resources so that they may choose a more cost-
1546effective setting for long-term placement, CARES staff shall
1547conduct an assessment and review of a sample of individuals
1548whose nursing home stay is expected to exceed 20 days,
1549regardless of the initial funding source for the nursing home
1550placement. CARES staff shall provide counseling and referral
1551services to these individuals regarding choosing appropriate
1552long-term care alternatives. This paragraph does not apply to
1553continuing care facilities licensed under chapter 651 or to
1554retirement communities that provide a combination of nursing
1555home, independent living, and other long-term care services.
1556     (e)  By January 15 of each year, the agency shall submit a
1557report to the Legislature describing the operations of the CARES
1558program. The report must describe:
1559     1.  Rate of diversion to community alternative programs;
1560     2.  CARES program staffing needs to achieve additional
1562     3.  Reasons the program is unable to place individuals in
1563less restrictive settings when such individuals desired such
1564services and could have been served in such settings;
1565     4.  Barriers to appropriate placement, including barriers
1566due to policies or operations of other agencies or state-funded
1567programs; and
1568     5.  Statutory changes necessary to ensure that individuals
1569in need of long-term care services receive care in the least
1570restrictive environment.
1571     (f)  The Department of Elderly Affairs shall track
1572individuals over time who are assessed under the CARES program
1573and who are diverted from nursing home placement. By January 15
1574of each year, the department shall submit to the Legislature a
1575longitudinal study of the individuals who are diverted from
1576nursing home placement. The study must include:
1577     1.  The demographic characteristics of the individuals
1578assessed and diverted from nursing home placement, including,
1579but not limited to, age, race, gender, frailty, caregiver
1580status, living arrangements, and geographic location;
1581     2.  A summary of community services provided to individuals
1582for 1 year after assessment and diversion;
1583     3.  A summary of inpatient hospital admissions for
1584individuals who have been diverted; and
1585     4.  A summary of the length of time between diversion and
1586subsequent entry into a nursing home or death.
1588This subsection expires October 1, 2013.
1589     (15)(16)(a)  The agency shall identify health care
1590utilization and price patterns within the Medicaid program which
1591are not cost-effective or medically appropriate and assess the
1592effectiveness of new or alternate methods of providing and
1593monitoring service, and may implement such methods as it
1594considers appropriate. Such methods may include disease
1595management initiatives, an integrated and systematic approach
1596for managing the health care needs of recipients who are at risk
1597of or diagnosed with a specific disease by using best practices,
1598prevention strategies, clinical-practice improvement, clinical
1599interventions and protocols, outcomes research, information
1600technology, and other tools and resources to reduce overall
1601costs and improve measurable outcomes.
1602     (b)  The responsibility of the agency under this subsection
1603shall include the development of capabilities to identify actual
1604and optimal practice patterns; patient and provider educational
1605initiatives; methods for determining patient compliance with
1606prescribed treatments; fraud, waste, and abuse prevention and
1607detection programs; and beneficiary case management programs.
1608     1.  The practice pattern identification program shall
1609evaluate practitioner prescribing patterns based on national and
1610regional practice guidelines, comparing practitioners to their
1611peer groups. The agency and its Drug Utilization Review Board
1612shall consult with the Department of Health and a panel of
1613practicing health care professionals consisting of the
1614following: the Speaker of the House of Representatives and the
1615President of the Senate shall each appoint three physicians
1616licensed under chapter 458 or chapter 459; and the Governor
1617shall appoint two pharmacists licensed under chapter 465 and one
1618dentist licensed under chapter 466 who is an oral surgeon. Terms
1619of the panel members shall expire at the discretion of the
1620appointing official. The advisory panel shall be responsible for
1621evaluating treatment guidelines and recommending ways to
1622incorporate their use in the practice pattern identification
1623program. Practitioners who are prescribing inappropriately or
1624inefficiently, as determined by the agency, may have their
1625prescribing of certain drugs subject to prior authorization or
1626may be terminated from all participation in the Medicaid
1628     2.  The agency shall also develop educational interventions
1629designed to promote the proper use of medications by providers
1630and beneficiaries.
1631     3.  The agency shall implement a pharmacy fraud, waste, and
1632abuse initiative that may include a surety bond or letter of
1633credit requirement for participating pharmacies, enhanced
1634provider auditing practices, the use of additional fraud and
1635abuse software, recipient management programs for beneficiaries
1636inappropriately using their benefits, and other steps that will
1637eliminate provider and recipient fraud, waste, and abuse. The
1638initiative shall address enforcement efforts to reduce the
1639number and use of counterfeit prescriptions.
1640     4.  By September 30, 2002, the agency shall contract with
1641an entity in the state to implement a wireless handheld clinical
1642pharmacology drug information database for practitioners. The
1643initiative shall be designed to enhance the agency's efforts to
1644reduce fraud, abuse, and errors in the prescription drug benefit
1645program and to otherwise further the intent of this paragraph.
1646     5.  By April 1, 2006, the agency shall contract with an
1647entity to design a database of clinical utilization information
1648or electronic medical records for Medicaid providers. This
1649system must be web-based and allow providers to review on a
1650real-time basis the utilization of Medicaid services, including,
1651but not limited to, physician office visits, inpatient and
1652outpatient hospitalizations, laboratory and pathology services,
1653radiological and other imaging services, dental care, and
1654patterns of dispensing prescription drugs in order to coordinate
1655care and identify potential fraud and abuse.
1656     6.  The agency may apply for any federal waivers needed to
1657administer this paragraph.
1659This subsection expires October 1, 2014.
1660     (16)(17)  An entity contracting on a prepaid or fixed-sum
1661basis shall meet the surplus requirements of s. 641.225. If an
1662entity's surplus falls below an amount equal to the surplus
1663requirements of s. 641.225, the agency shall prohibit the entity
1664from engaging in marketing and preenrollment activities, shall
1665cease to process new enrollments, and may not renew the entity's
1666contract until the required balance is achieved. The
1667requirements of this subsection do not apply:
1668     (a)  Where a public entity agrees to fund any deficit
1669incurred by the contracting entity; or
1670     (b)  Where the entity's performance and obligations are
1671guaranteed in writing by a guaranteeing organization which:
1672     1.  Has been in operation for at least 5 years and has
1673assets in excess of $50 million; or
1674     2.  Submits a written guarantee acceptable to the agency
1675which is irrevocable during the term of the contracting entity's
1676contract with the agency and, upon termination of the contract,
1677until the agency receives proof of satisfaction of all
1678outstanding obligations incurred under the contract.
1680This subsection expires October 1, 2014.
1681     (17)(18)(a)  The agency may require an entity contracting
1682on a prepaid or fixed-sum basis to establish a restricted
1683insolvency protection account with a federally guaranteed
1684financial institution licensed to do business in this state. The
1685entity shall deposit into that account 5 percent of the
1686capitation payments made by the agency each month until a
1687maximum total of 2 percent of the total current contract amount
1688is reached. The restricted insolvency protection account may be
1689drawn upon with the authorized signatures of two persons
1690designated by the entity and two representatives of the agency.
1691If the agency finds that the entity is insolvent, the agency may
1692draw upon the account solely with the two authorized signatures
1693of representatives of the agency, and the funds may be disbursed
1694to meet financial obligations incurred by the entity under the
1695prepaid contract. If the contract is terminated, expired, or not
1696continued, the account balance must be released by the agency to
1697the entity upon receipt of proof of satisfaction of all
1698outstanding obligations incurred under this contract.
1699     (b)  The agency may waive the insolvency protection account
1700requirement in writing when evidence is on file with the agency
1701of adequate insolvency insurance and reinsurance that will
1702protect enrollees if the entity becomes unable to meet its
1705     (18)(19)  An entity that contracts with the agency on a
1706prepaid or fixed-sum basis for the provision of Medicaid
1707services shall reimburse any hospital or physician that is
1708outside the entity's authorized geographic service area as
1709specified in its contract with the agency, and that provides
1710services authorized by the entity to its members, at a rate
1711negotiated with the hospital or physician for the provision of
1712services or according to the lesser of the following:
1713     (a)  The usual and customary charges made to the general
1714public by the hospital or physician; or
1715     (b)  The Florida Medicaid reimbursement rate established
1716for the hospital or physician.
1718This subsection expires October 1, 2014.
1719     (19)(20)  When a merger or acquisition of a Medicaid
1720prepaid contractor has been approved by the Office of Insurance
1721Regulation pursuant to s. 628.4615, the agency shall approve the
1722assignment or transfer of the appropriate Medicaid prepaid
1723contract upon request of the surviving entity of the merger or
1724acquisition if the contractor and the other entity have been in
1725good standing with the agency for the most recent 12-month
1726period, unless the agency determines that the assignment or
1727transfer would be detrimental to the Medicaid recipients or the
1728Medicaid program. To be in good standing, an entity must not
1729have failed accreditation or committed any material violation of
1730the requirements of s. 641.52 and must meet the Medicaid
1731contract requirements. For purposes of this section, a merger or
1732acquisition means a change in controlling interest of an entity,
1733including an asset or stock purchase. This subsection expires
1734October 1, 2014.
1735     (20)(21)  Any entity contracting with the agency pursuant
1736to this section to provide health care services to Medicaid
1737recipients is prohibited from engaging in any of the following
1738practices or activities:
1739     (a)  Practices that are discriminatory, including, but not
1740limited to, attempts to discourage participation on the basis of
1741actual or perceived health status.
1742     (b)  Activities that could mislead or confuse recipients,
1743or misrepresent the organization, its marketing representatives,
1744or the agency. Violations of this paragraph include, but are not
1745limited to:
1746     1.  False or misleading claims that marketing
1747representatives are employees or representatives of the state or
1748county, or of anyone other than the entity or the organization
1749by whom they are reimbursed.
1750     2.  False or misleading claims that the entity is
1751recommended or endorsed by any state or county agency, or by any
1752other organization which has not certified its endorsement in
1753writing to the entity.
1754     3.  False or misleading claims that the state or county
1755recommends that a Medicaid recipient enroll with an entity.
1756     4.  Claims that a Medicaid recipient will lose benefits
1757under the Medicaid program, or any other health or welfare
1758benefits to which the recipient is legally entitled, if the
1759recipient does not enroll with the entity.
1760     (c)  Granting or offering of any monetary or other valuable
1761consideration for enrollment, except as authorized by subsection
1762(23) (24).
1763     (d)  Door-to-door solicitation of recipients who have not
1764contacted the entity or who have not invited the entity to make
1765a presentation.
1766     (e)  Solicitation of Medicaid recipients by marketing
1767representatives stationed in state offices unless approved and
1768supervised by the agency or its agent and approved by the
1769affected state agency when solicitation occurs in an office of
1770the state agency. The agency shall ensure that marketing
1771representatives stationed in state offices shall market their
1772managed care plans to Medicaid recipients only in designated
1773areas and in such a way as to not interfere with the recipients'
1774activities in the state office.
1775     (f)  Enrollment of Medicaid recipients.
1777     (21)(22)  The agency may impose a fine for a violation of
1778this section or the contract with the agency by a person or
1779entity that is under contract with the agency. With respect to
1780any nonwillful violation, such fine shall not exceed $2,500 per
1781violation. In no event shall such fine exceed an aggregate
1782amount of $10,000 for all nonwillful violations arising out of
1783the same action. With respect to any knowing and willful
1784violation of this section or the contract with the agency, the
1785agency may impose a fine upon the entity in an amount not to
1786exceed $20,000 for each such violation. In no event shall such
1787fine exceed an aggregate amount of $100,000 for all knowing and
1788willful violations arising out of the same action. This
1789subsection expires October 1, 2014.
1790     (22)(23)  A health maintenance organization or a person or
1791entity exempt from chapter 641 that is under contract with the
1792agency for the provision of health care services to Medicaid
1793recipients may not use or distribute marketing materials used to
1794solicit Medicaid recipients, unless such materials have been
1795approved by the agency. The provisions of this subsection do not
1796apply to general advertising and marketing materials used by a
1797health maintenance organization to solicit both non-Medicaid
1798subscribers and Medicaid recipients. This subsection expires
1799October 1, 2014.
1800     (23)(24)  Upon approval by the agency, health maintenance
1801organizations and persons or entities exempt from chapter 641
1802that are under contract with the agency for the provision of
1803health care services to Medicaid recipients may be permitted
1804within the capitation rate to provide additional health benefits
1805that the agency has found are of high quality, are practicably
1806available, provide reasonable value to the recipient, and are
1807provided at no additional cost to the state. This subsection
1808expires October 1, 2014.
1809     (24)(25)  The agency shall utilize the statewide health
1810maintenance organization complaint hotline for the purpose of
1811investigating and resolving Medicaid and prepaid health plan
1812complaints, maintaining a record of complaints and confirmed
1813problems, and receiving disenrollment requests made by
1814recipients. This subsection expires October 1, 2014.
1815     (25)(26)  The agency shall require the publication of the
1816health maintenance organization's and the prepaid health plan's
1817consumer services telephone numbers and the "800" telephone
1818number of the statewide health maintenance organization
1819complaint hotline on each Medicaid identification card issued by
1820a health maintenance organization or prepaid health plan
1821contracting with the agency to serve Medicaid recipients and on
1822each subscriber handbook issued to a Medicaid recipient. This
1823subsection expires October 1, 2014.
1824     (26)(27)  The agency shall establish a health care quality
1825improvement system for those entities contracting with the
1826agency pursuant to this section, incorporating all the standards
1827and guidelines developed by the Medicaid Bureau of the Health
1828Care Financing Administration as a part of the quality assurance
1829reform initiative. The system shall include, but need not be
1830limited to, the following:
1831     (a)  Guidelines for internal quality assurance programs,
1832including standards for:
1833     1.  Written quality assurance program descriptions.
1834     2.  Responsibilities of the governing body for monitoring,
1835evaluating, and making improvements to care.
1836     3.  An active quality assurance committee.
1837     4.  Quality assurance program supervision.
1838     5.  Requiring the program to have adequate resources to
1839effectively carry out its specified activities.
1840     6.  Provider participation in the quality assurance
1842     7.  Delegation of quality assurance program activities.
1843     8.  Credentialing and recredentialing.
1844     9.  Enrollee rights and responsibilities.
1845     10.  Availability and accessibility to services and care.
1846     11.  Ambulatory care facilities.
1847     12.  Accessibility and availability of medical records, as
1848well as proper recordkeeping and process for record review.
1849     13.  Utilization review.
1850     14.  A continuity of care system.
1851     15.  Quality assurance program documentation.
1852     16.  Coordination of quality assurance activity with other
1853management activity.
1854     17.  Delivering care to pregnant women and infants; to
1855elderly and disabled recipients, especially those who are at
1856risk of institutional placement; to persons with developmental
1857disabilities; and to adults who have chronic, high-cost medical
1859     (b)  Guidelines which require the entities to conduct
1860quality-of-care studies which:
1861     1.  Target specific conditions and specific health service
1862delivery issues for focused monitoring and evaluation.
1863     2.  Use clinical care standards or practice guidelines to
1864objectively evaluate the care the entity delivers or fails to
1865deliver for the targeted clinical conditions and health services
1866delivery issues.
1867     3.  Use quality indicators derived from the clinical care
1868standards or practice guidelines to screen and monitor care and
1869services delivered.
1870     (c)  Guidelines for external quality review of each
1871contractor which require: focused studies of patterns of care;
1872individual care review in specific situations; and followup
1873activities on previous pattern-of-care study findings and
1874individual-care-review findings. In designing the external
1875quality review function and determining how it is to operate as
1876part of the state's overall quality improvement system, the
1877agency shall construct its external quality review organization
1878and entity contracts to address each of the following:
1879     1.  Delineating the role of the external quality review
1881     2.  Length of the external quality review organization
1882contract with the state.
1883     3.  Participation of the contracting entities in designing
1884external quality review organization review activities.
1885     4.  Potential variation in the type of clinical conditions
1886and health services delivery issues to be studied at each plan.
1887     5.  Determining the number of focused pattern-of-care
1888studies to be conducted for each plan.
1889     6.  Methods for implementing focused studies.
1890     7.  Individual care review.
1891     8.  Followup activities.
1893This subsection expires October 1, 2016.
1894     (27)(28)  In order to ensure that children receive health
1895care services for which an entity has already been compensated,
1896an entity contracting with the agency pursuant to this section
1897shall achieve an annual Early and Periodic Screening, Diagnosis,
1898and Treatment (EPSDT) Service screening rate of at least 60
1899percent for those recipients continuously enrolled for at least
19008 months. The agency shall develop a method by which the EPSDT
1901screening rate shall be calculated. For any entity which does
1902not achieve the annual 60 percent rate, the entity must submit a
1903corrective action plan for the agency's approval. If the entity
1904does not meet the standard established in the corrective action
1905plan during the specified timeframe, the agency is authorized to
1906impose appropriate contract sanctions. At least annually, the
1907agency shall publicly release the EPSDT Services screening rates
1908of each entity it has contracted with on a prepaid basis to
1909serve Medicaid recipients. This subsection expires October 1,
1911     (28)(29)  The agency shall perform enrollments and
1912disenrollments for Medicaid recipients who are eligible for
1913MediPass or managed care plans. Notwithstanding the prohibition
1914contained in paragraph (20)(21)(f), managed care plans may
1915perform preenrollments of Medicaid recipients under the
1916supervision of the agency or its agents. For the purposes of
1917this section, the term "preenrollment" means the provision of
1918marketing and educational materials to a Medicaid recipient and
1919assistance in completing the application forms, but does not
1920include actual enrollment into a managed care plan. An
1921application for enrollment may not be deemed complete until the
1922agency or its agent verifies that the recipient made an
1923informed, voluntary choice. The agency, in cooperation with the
1924Department of Children and Family Services, may test new
1925marketing initiatives to inform Medicaid recipients about their
1926managed care options at selected sites. The agency may contract
1927with a third party to perform managed care plan and MediPass
1928enrollment and disenrollment services for Medicaid recipients
1929and may adopt rules to administer such services. The agency may
1930adjust the capitation rate only to cover the costs of a third-
1931party enrollment and disenrollment contract, and for agency
1932supervision and management of the managed care plan enrollment
1933and disenrollment contract. This subsection expires October 1,
1935     (29)(30)  Any lists of providers made available to Medicaid
1936recipients, MediPass enrollees, or managed care plan enrollees
1937shall be arranged alphabetically showing the provider's name and
1938specialty and, separately, by specialty in alphabetical order.
1939This subsection expires October 1, 2014.
1940     (30)(31)  The agency shall establish an enhanced managed
1941care quality assurance oversight function, to include at least
1942the following components:
1943     (a)  At least quarterly analysis and followup, including
1944sanctions as appropriate, of managed care participant
1945utilization of services.
1946     (b)  At least quarterly analysis and followup, including
1947sanctions as appropriate, of quality findings of the Medicaid
1948peer review organization and other external quality assurance
1950     (c)  At least quarterly analysis and followup, including
1951sanctions as appropriate, of the fiscal viability of managed
1952care plans.
1953     (d)  At least quarterly analysis and followup, including
1954sanctions as appropriate, of managed care participant
1955satisfaction and disenrollment surveys.
1956     (e)  The agency shall conduct regular and ongoing Medicaid
1957recipient satisfaction surveys.
1959The analyses and followup activities conducted by the agency
1960under its enhanced managed care quality assurance oversight
1961function shall not duplicate the activities of accreditation
1962reviewers for entities regulated under part III of chapter 641,
1963but may include a review of the finding of such reviewers. This
1964subsection expires October 1, 2014.
1965     (31)(32)  Each managed care plan that is under contract
1966with the agency to provide health care services to Medicaid
1967recipients shall annually conduct a background check with the
1968Department of Law Enforcement of all persons with ownership
1969interest of 5 percent or more or executive management
1970responsibility for the managed care plan and shall submit to the
1971agency information concerning any such person who has been found
1972guilty of, regardless of adjudication, or has entered a plea of
1973nolo contendere or guilty to, any of the offenses listed in s.
1974435.04. This subsection expires October 1, 2014.
1975     (32)(33)  The agency shall, by rule, develop a process
1976whereby a Medicaid managed care plan enrollee who wishes to
1977enter hospice care may be disenrolled from the managed care plan
1978within 24 hours after contacting the agency regarding such
1979request. The agency rule shall include a methodology for the
1980agency to recoup managed care plan payments on a pro rata basis
1981if payment has been made for the enrollment month when
1982disenrollment occurs. This subsection expires October 1, 2014.
1983     (33)(34)  The agency and entities that contract with the
1984agency to provide health care services to Medicaid recipients
1985under this section or ss. 409.91211 and 409.9122 must comply
1986with the provisions of s. 641.513 in providing emergency
1987services and care to Medicaid recipients and MediPass
1988recipients. Where feasible, safe, and cost-effective, the agency
1989shall encourage hospitals, emergency medical services providers,
1990and other public and private health care providers to work
1991together in their local communities to enter into agreements or
1992arrangements to ensure access to alternatives to emergency
1993services and care for those Medicaid recipients who need
1994nonemergent care. The agency shall coordinate with hospitals,
1995emergency medical services providers, private health plans,
1996capitated managed care networks as established in s. 409.91211,
1997and other public and private health care providers to implement
1998the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1999and 641.31097 to develop and implement emergency department
2000diversion programs for Medicaid recipients. This subsection
2001expires October 1, 2014.
2002     (34)(35)  All entities providing health care services to
2003Medicaid recipients shall make available, and encourage all
2004pregnant women and mothers with infants to receive, and provide
2005documentation in the medical records to reflect, the following:
2006     (a)  Healthy Start prenatal or infant screening.
2007     (b)  Healthy Start care coordination, when screening or
2008other factors indicate need.
2009     (c)  Healthy Start enhanced services in accordance with the
2010prenatal or infant screening results.
2011     (d)  Immunizations in accordance with recommendations of
2012the Advisory Committee on Immunization Practices of the United
2013States Public Health Service and the American Academy of
2014Pediatrics, as appropriate.
2015     (e)  Counseling and services for family planning to all
2016women and their partners.
2017     (f)  A scheduled postpartum visit for the purpose of
2018voluntary family planning, to include discussion of all methods
2019of contraception, as appropriate.
2020     (g)  Referral to the Special Supplemental Nutrition Program
2021for Women, Infants, and Children (WIC).
2023This subsection expires October 1, 2014.
2024     (35)(36)  Any entity that provides Medicaid prepaid health
2025plan services shall ensure the appropriate coordination of
2026health care services with an assisted living facility in cases
2027where a Medicaid recipient is both a member of the entity's
2028prepaid health plan and a resident of the assisted living
2029facility. If the entity is at risk for Medicaid targeted case
2030management and behavioral health services, the entity shall
2031inform the assisted living facility of the procedures to follow
2032should an emergent condition arise. This subsection expires
2033October 1, 2014.
2034     (37)  The agency may seek and implement federal waivers
2035necessary to provide for cost-effective purchasing of home
2036health services, private duty nursing services, transportation,
2037independent laboratory services, and durable medical equipment
2038and supplies through competitive bidding pursuant to s. 287.057.
2039The agency may request appropriate waivers from the federal
2040Health Care Financing Administration in order to competitively
2041bid such services. The agency may exclude providers not selected
2042through the bidding process from the Medicaid provider network.
2043     (36)(38)  The agency shall enter into agreements with not-
2044for-profit organizations based in this state for the purpose of
2045providing vision screening. This subsection expires October 1,
2047     (37)(39)(a)  The agency shall implement a Medicaid
2048prescribed-drug spending-control program that includes the
2049following components:
2050     1.  A Medicaid preferred drug list, which shall be a
2051listing of cost-effective therapeutic options recommended by the
2052Medicaid Pharmacy and Therapeutics Committee established
2053pursuant to s. 409.91195 and adopted by the agency for each
2054therapeutic class on the preferred drug list. At the discretion
2055of the committee, and when feasible, the preferred drug list
2056should include at least two products in a therapeutic class. The
2057agency may post the preferred drug list and updates to the
2058preferred drug list on an Internet website without following the
2059rulemaking procedures of chapter 120. Antiretroviral agents are
2060excluded from the preferred drug list. The agency shall also
2061limit the amount of a prescribed drug dispensed to no more than
2062a 34-day supply unless the drug products' smallest marketed
2063package is greater than a 34-day supply, or the drug is
2064determined by the agency to be a maintenance drug in which case
2065a 100-day maximum supply may be authorized. The agency is
2066authorized to seek any federal waivers necessary to implement
2067these cost-control programs and to continue participation in the
2068federal Medicaid rebate program, or alternatively to negotiate
2069state-only manufacturer rebates. The agency may adopt rules to
2070implement this subparagraph. The agency shall continue to
2071provide unlimited contraceptive drugs and items. The agency must
2072establish procedures to ensure that:
2073     a.  There is a response to a request for prior consultation
2074by telephone or other telecommunication device within 24 hours
2075after receipt of a request for prior consultation; and
2076     b.  A 72-hour supply of the drug prescribed is provided in
2077an emergency or when the agency does not provide a response
2078within 24 hours as required by sub-subparagraph a.
2079     2.  Reimbursement to pharmacies for Medicaid prescribed
2080drugs shall be set at the lesser of: the average wholesale price
2081(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2082plus 4.75 percent, the federal upper limit (FUL), the state
2083maximum allowable cost (SMAC), or the usual and customary (UAC)
2084charge billed by the provider.
2085     3.  The agency shall develop and implement a process for
2086managing the drug therapies of Medicaid recipients who are using
2087significant numbers of prescribed drugs each month. The
2088management process may include, but is not limited to,
2089comprehensive, physician-directed medical-record reviews, claims
2090analyses, and case evaluations to determine the medical
2091necessity and appropriateness of a patient's treatment plan and
2092drug therapies. The agency may contract with a private
2093organization to provide drug-program-management services. The
2094Medicaid drug benefit management program shall include
2095initiatives to manage drug therapies for HIV/AIDS patients,
2096patients using 20 or more unique prescriptions in a 180-day
2097period, and the top 1,000 patients in annual spending. The
2098agency shall enroll any Medicaid recipient in the drug benefit
2099management program if he or she meets the specifications of this
2100provision and is not enrolled in a Medicaid health maintenance
2102     4.  The agency may limit the size of its pharmacy network
2103based on need, competitive bidding, price negotiations,
2104credentialing, or similar criteria. The agency shall give
2105special consideration to rural areas in determining the size and
2106location of pharmacies included in the Medicaid pharmacy
2107network. A pharmacy credentialing process may include criteria
2108such as a pharmacy's full-service status, location, size,
2109patient educational programs, patient consultation, disease
2110management services, and other characteristics. The agency may
2111impose a moratorium on Medicaid pharmacy enrollment when it is
2112determined that it has a sufficient number of Medicaid-
2113participating providers. The agency must allow dispensing
2114practitioners to participate as a part of the Medicaid pharmacy
2115network regardless of the practitioner's proximity to any other
2116entity that is dispensing prescription drugs under the Medicaid
2117program. A dispensing practitioner must meet all credentialing
2118requirements applicable to his or her practice, as determined by
2119the agency.
2120     5.  The agency shall develop and implement a program that
2121requires Medicaid practitioners who prescribe drugs to use a
2122counterfeit-proof prescription pad for Medicaid prescriptions.
2123The agency shall require the use of standardized counterfeit-
2124proof prescription pads by Medicaid-participating prescribers or
2125prescribers who write prescriptions for Medicaid recipients. The
2126agency may implement the program in targeted geographic areas or
2128     6.  The agency may enter into arrangements that require
2129manufacturers of generic drugs prescribed to Medicaid recipients
2130to provide rebates of at least 15.1 percent of the average
2131manufacturer price for the manufacturer's generic products.
2132These arrangements shall require that if a generic-drug
2133manufacturer pays federal rebates for Medicaid-reimbursed drugs
2134at a level below 15.1 percent, the manufacturer must provide a
2135supplemental rebate to the state in an amount necessary to
2136achieve a 15.1-percent rebate level.
2137     7.  The agency may establish a preferred drug list as
2138described in this subsection, and, pursuant to the establishment
2139of such preferred drug list, it is authorized to negotiate
2140supplemental rebates from manufacturers that are in addition to
2141those required by Title XIX of the Social Security Act and at no
2142less than 14 percent of the average manufacturer price as
2143defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2144the federal or supplemental rebate, or both, equals or exceeds
214529 percent. There is no upper limit on the supplemental rebates
2146the agency may negotiate. The agency may determine that specific
2147products, brand-name or generic, are competitive at lower rebate
2148percentages. Agreement to pay the minimum supplemental rebate
2149percentage will guarantee a manufacturer that the Medicaid
2150Pharmaceutical and Therapeutics Committee will consider a
2151product for inclusion on the preferred drug list. However, a
2152pharmaceutical manufacturer is not guaranteed placement on the
2153preferred drug list by simply paying the minimum supplemental
2154rebate. Agency decisions will be made on the clinical efficacy
2155of a drug and recommendations of the Medicaid Pharmaceutical and
2156Therapeutics Committee, as well as the price of competing
2157products minus federal and state rebates. The agency is
2158authorized to contract with an outside agency or contractor to
2159conduct negotiations for supplemental rebates. For the purposes
2160of this section, the term "supplemental rebates" means cash
2161rebates. Effective July 1, 2004, value-added programs as a
2162substitution for supplemental rebates are prohibited. The agency
2163is authorized to seek any federal waivers to implement this
2165     8.  The Agency for Health Care Administration shall expand
2166home delivery of pharmacy products. To assist Medicaid patients
2167in securing their prescriptions and reduce program costs, the
2168agency shall expand its current mail-order-pharmacy diabetes-
2169supply program to include all generic and brand-name drugs used
2170by Medicaid patients with diabetes. Medicaid recipients in the
2171current program may obtain nondiabetes drugs on a voluntary
2172basis. This initiative is limited to the geographic area covered
2173by the current contract. The agency may seek and implement any
2174federal waivers necessary to implement this subparagraph.
2175     9.  The agency shall limit to one dose per month any drug
2176prescribed to treat erectile dysfunction.
2177     10.a.  The agency may implement a Medicaid behavioral drug
2178management system. The agency may contract with a vendor that
2179has experience in operating behavioral drug management systems
2180to implement this program. The agency is authorized to seek
2181federal waivers to implement this program.
2182     b.  The agency, in conjunction with the Department of
2183Children and Family Services, may implement the Medicaid
2184behavioral drug management system that is designed to improve
2185the quality of care and behavioral health prescribing practices
2186based on best practice guidelines, improve patient adherence to
2187medication plans, reduce clinical risk, and lower prescribed
2188drug costs and the rate of inappropriate spending on Medicaid
2189behavioral drugs. The program may include the following
2191     (I)  Provide for the development and adoption of best
2192practice guidelines for behavioral health-related drugs such as
2193antipsychotics, antidepressants, and medications for treating
2194bipolar disorders and other behavioral conditions; translate
2195them into practice; review behavioral health prescribers and
2196compare their prescribing patterns to a number of indicators
2197that are based on national standards; and determine deviations
2198from best practice guidelines.
2199     (II)  Implement processes for providing feedback to and
2200educating prescribers using best practice educational materials
2201and peer-to-peer consultation.
2202     (III)  Assess Medicaid beneficiaries who are outliers in
2203their use of behavioral health drugs with regard to the numbers
2204and types of drugs taken, drug dosages, combination drug
2205therapies, and other indicators of improper use of behavioral
2206health drugs.
2207     (IV)  Alert prescribers to patients who fail to refill
2208prescriptions in a timely fashion, are prescribed multiple same-
2209class behavioral health drugs, and may have other potential
2210medication problems.
2211     (V)  Track spending trends for behavioral health drugs and
2212deviation from best practice guidelines.
2213     (VI)  Use educational and technological approaches to
2214promote best practices, educate consumers, and train prescribers
2215in the use of practice guidelines.
2216     (VII)  Disseminate electronic and published materials.
2217     (VIII)  Hold statewide and regional conferences.
2218     (IX)  Implement a disease management program with a model
2219quality-based medication component for severely mentally ill
2220individuals and emotionally disturbed children who are high
2221users of care.
2222     11.a.  The agency shall implement a Medicaid prescription
2223drug management system. The agency may contract with a vendor
2224that has experience in operating prescription drug management
2225systems in order to implement this system. Any management system
2226that is implemented in accordance with this subparagraph must
2227rely on cooperation between physicians and pharmacists to
2228determine appropriate practice patterns and clinical guidelines
2229to improve the prescribing, dispensing, and use of drugs in the
2230Medicaid program. The agency may seek federal waivers to
2231implement this program.
2232     b.  The drug management system must be designed to improve
2233the quality of care and prescribing practices based on best
2234practice guidelines, improve patient adherence to medication
2235plans, reduce clinical risk, and lower prescribed drug costs and
2236the rate of inappropriate spending on Medicaid prescription
2237drugs. The program must:
2238     (I)  Provide for the development and adoption of best
2239practice guidelines for the prescribing and use of drugs in the
2240Medicaid program, including translating best practice guidelines
2241into practice; reviewing prescriber patterns and comparing them
2242to indicators that are based on national standards and practice
2243patterns of clinical peers in their community, statewide, and
2244nationally; and determine deviations from best practice
2246     (II)  Implement processes for providing feedback to and
2247educating prescribers using best practice educational materials
2248and peer-to-peer consultation.
2249     (III)  Assess Medicaid recipients who are outliers in their
2250use of a single or multiple prescription drugs with regard to
2251the numbers and types of drugs taken, drug dosages, combination
2252drug therapies, and other indicators of improper use of
2253prescription drugs.
2254     (IV)  Alert prescribers to patients who fail to refill
2255prescriptions in a timely fashion, are prescribed multiple drugs
2256that may be redundant or contraindicated, or may have other
2257potential medication problems.
2258     (V)  Track spending trends for prescription drugs and
2259deviation from best practice guidelines.
2260     (VI)  Use educational and technological approaches to
2261promote best practices, educate consumers, and train prescribers
2262in the use of practice guidelines.
2263     (VII)  Disseminate electronic and published materials.
2264     (VIII)  Hold statewide and regional conferences.
2265     (IX)  Implement disease management programs in cooperation
2266with physicians and pharmacists, along with a model quality-
2267based medication component for individuals having chronic
2268medical conditions.
2269     12.  The agency is authorized to contract for drug rebate
2270administration, including, but not limited to, calculating
2271rebate amounts, invoicing manufacturers, negotiating disputes
2272with manufacturers, and maintaining a database of rebate
2274     13.  The agency may specify the preferred daily dosing form
2275or strength for the purpose of promoting best practices with
2276regard to the prescribing of certain drugs as specified in the
2277General Appropriations Act and ensuring cost-effective
2278prescribing practices.
2279     14.  The agency may require prior authorization for
2280Medicaid-covered prescribed drugs. The agency may, but is not
2281required to, prior-authorize the use of a product:
2282     a.  For an indication not approved in labeling;
2283     b.  To comply with certain clinical guidelines; or
2284     c.  If the product has the potential for overuse, misuse,
2285or abuse.
2287The agency may require the prescribing professional to provide
2288information about the rationale and supporting medical evidence
2289for the use of a drug. The agency may post prior authorization
2290criteria and protocol and updates to the list of drugs that are
2291subject to prior authorization on an Internet website without
2292amending its rule or engaging in additional rulemaking.
2293     15.  The agency, in conjunction with the Pharmaceutical and
2294Therapeutics Committee, may require age-related prior
2295authorizations for certain prescribed drugs. The agency may
2296preauthorize the use of a drug for a recipient who may not meet
2297the age requirement or may exceed the length of therapy for use
2298of this product as recommended by the manufacturer and approved
2299by the Food and Drug Administration. Prior authorization may
2300require the prescribing professional to provide information
2301about the rationale and supporting medical evidence for the use
2302of a drug.
2303     16.  The agency shall implement a step-therapy prior
2304authorization approval process for medications excluded from the
2305preferred drug list. Medications listed on the preferred drug
2306list must be used within the previous 12 months prior to the
2307alternative medications that are not listed. The step-therapy
2308prior authorization may require the prescriber to use the
2309medications of a similar drug class or for a similar medical
2310indication unless contraindicated in the Food and Drug
2311Administration labeling. The trial period between the specified
2312steps may vary according to the medical indication. The step-
2313therapy approval process shall be developed in accordance with
2314the committee as stated in s. 409.91195(7) and (8). A drug
2315product may be approved without meeting the step-therapy prior
2316authorization criteria if the prescribing physician provides the
2317agency with additional written medical or clinical documentation
2318that the product is medically necessary because:
2319     a.  There is not a drug on the preferred drug list to treat
2320the disease or medical condition which is an acceptable clinical
2322     b.  The alternatives have been ineffective in the treatment
2323of the beneficiary's disease; or
2324     c.  Based on historic evidence and known characteristics of
2325the patient and the drug, the drug is likely to be ineffective,
2326or the number of doses have been ineffective.
2328The agency shall work with the physician to determine the best
2329alternative for the patient. The agency may adopt rules waiving
2330the requirements for written clinical documentation for specific
2331drugs in limited clinical situations.
2332     17.  The agency shall implement a return and reuse program
2333for drugs dispensed by pharmacies to institutional recipients,
2334which includes payment of a $5 restocking fee for the
2335implementation and operation of the program. The return and
2336reuse program shall be implemented electronically and in a
2337manner that promotes efficiency. The program must permit a
2338pharmacy to exclude drugs from the program if it is not
2339practical or cost-effective for the drug to be included and must
2340provide for the return to inventory of drugs that cannot be
2341credited or returned in a cost-effective manner. The agency
2342shall determine if the program has reduced the amount of
2343Medicaid prescription drugs which are destroyed on an annual
2344basis and if there are additional ways to ensure more
2345prescription drugs are not destroyed which could safely be
2346reused. The agency's conclusion and recommendations shall be
2347reported to the Legislature by December 1, 2005.
2348     (b)  The agency shall implement this subsection to the
2349extent that funds are appropriated to administer the Medicaid
2350prescribed-drug spending-control program. The agency may
2351contract all or any part of this program to private
2353     (c)  The agency shall submit quarterly reports to the
2354Governor, the President of the Senate, and the Speaker of the
2355House of Representatives which must include, but need not be
2356limited to, the progress made in implementing this subsection
2357and its effect on Medicaid prescribed-drug expenditures.
2358     (38)(40)  Notwithstanding the provisions of chapter 287,
2359the agency may, at its discretion, renew a contract or contracts
2360for fiscal intermediary services one or more times for such
2361periods as the agency may decide; however, all such renewals may
2362not combine to exceed a total period longer than the term of the
2363original contract.
2364     (39)(41)  The agency shall provide for the development of a
2365demonstration project by establishment in Miami-Dade County of a
2366long-term-care facility licensed pursuant to chapter 395 to
2367improve access to health care for a predominantly minority,
2368medically underserved, and medically complex population and to
2369evaluate alternatives to nursing home care and general acute
2370care for such population. Such project is to be located in a
2371health care condominium and colocated with licensed facilities
2372providing a continuum of care. The establishment of this project
2373is not subject to the provisions of s. 408.036 or s. 408.039.
2374This subsection expires October 1, 2013.
2375     (40)(42)  The agency shall develop and implement a
2376utilization management program for Medicaid-eligible recipients
2377for the management of occupational, physical, respiratory, and
2378speech therapies. The agency shall establish a utilization
2379program that may require prior authorization in order to ensure
2380medically necessary and cost-effective treatments. The program
2381shall be operated in accordance with a federally approved waiver
2382program or state plan amendment. The agency may seek a federal
2383waiver or state plan amendment to implement this program. The
2384agency may also competitively procure these services from an
2385outside vendor on a regional or statewide basis. This subsection
2386expires October 1, 2014.
2387     (41)(43)  The agency shall may contract on a prepaid or
2388fixed-sum basis with appropriately licensed prepaid dental
2389health plans to provide dental services. This subsection expires
2390October 1, 2014.
2391     (42)(44)  The Agency for Health Care Administration shall
2392ensure that any Medicaid managed care plan as defined in s.
2393409.9122(2)(f), whether paid on a capitated basis or a shared
2394savings basis, is cost-effective. For purposes of this
2395subsection, the term "cost-effective" means that a network's
2396per-member, per-month costs to the state, including, but not
2397limited to, fee-for-service costs, administrative costs, and
2398case-management fees, if any, must be no greater than the
2399state's costs associated with contracts for Medicaid services
2400established under subsection (3), which may be adjusted for
2401health status. The agency shall conduct actuarially sound
2402adjustments for health status in order to ensure such cost-
2403effectiveness and shall annually publish the results on its
2404Internet website. Contracts established pursuant to this
2405subsection which are not cost-effective may not be renewed. This
2406subsection expires October 1, 2014.
2407     (43)(45)  Subject to the availability of funds, the agency
2408shall mandate a recipient's participation in a provider lock-in
2409program, when appropriate, if a recipient is found by the agency
2410to have used Medicaid goods or services at a frequency or amount
2411not medically necessary, limiting the receipt of goods or
2412services to medically necessary providers after the 21-day
2413appeal process has ended, for a period of not less than 1 year.
2414The lock-in programs shall include, but are not limited to,
2415pharmacies, medical doctors, and infusion clinics. The
2416limitation does not apply to emergency services and care
2417provided to the recipient in a hospital emergency department.
2418The agency shall seek any federal waivers necessary to implement
2419this subsection. The agency shall adopt any rules necessary to
2420comply with or administer this subsection. This subsection
2421expires October 1, 2014.
2422     (44)(46)  The agency shall seek a federal waiver for
2423permission to terminate the eligibility of a Medicaid recipient
2424who has been found to have committed fraud, through judicial or
2425administrative determination, two times in a period of 5 years.
2426     (47)  The agency shall conduct a study of available
2427electronic systems for the purpose of verifying the identity and
2428eligibility of a Medicaid recipient. The agency shall recommend
2429to the Legislature a plan to implement an electronic
2430verification system for Medicaid recipients by January 31, 2005.
2431     (45)(48)(a)  A provider is not entitled to enrollment in
2432the Medicaid provider network. The agency may implement a
2433Medicaid fee-for-service provider network controls, including,
2434but not limited to, competitive procurement and provider
2435credentialing. If a credentialing process is used, the agency
2436may limit its provider network based upon the following
2437considerations: beneficiary access to care, provider
2438availability, provider quality standards and quality assurance
2439processes, cultural competency, demographic characteristics of
2440beneficiaries, practice standards, service wait times, provider
2441turnover, provider licensure and accreditation history, program
2442integrity history, peer review, Medicaid policy and billing
2443compliance records, clinical and medical record audit findings,
2444and such other areas that are considered necessary by the agency
2445to ensure the integrity of the program.
2446     (b)  The agency shall limit its network of durable medical
2447equipment and medical supply providers. For dates of service
2448after January 1, 2009, the agency shall limit payment for
2449durable medical equipment and supplies to providers that meet
2450all the requirements of this paragraph.
2451     1.  Providers must be accredited by a Centers for Medicare
2452and Medicaid Services deemed accreditation organization for
2453suppliers of durable medical equipment, prosthetics, orthotics,
2454and supplies. The provider must maintain accreditation and is
2455subject to unannounced reviews by the accrediting organization.
2456     2.  Providers must provide the services or supplies
2457directly to the Medicaid recipient or caregiver at the provider
2458location or recipient's residence or send the supplies directly
2459to the recipient's residence with receipt of mailed delivery.
2460Subcontracting or consignment of the service or supply to a
2461third party is prohibited.
2462     3.  Notwithstanding subparagraph 2., a durable medical
2463equipment provider may store nebulizers at a physician's office
2464for the purpose of having the physician's staff issue the
2465equipment if it meets all of the following conditions:
2466     a.  The physician must document the medical necessity and
2467need to prevent further deterioration of the patient's
2468respiratory status by the timely delivery of the nebulizer in
2469the physician's office.
2470     b.  The durable medical equipment provider must have
2471written documentation of the competency and training by a
2472Florida-licensed registered respiratory therapist of any durable
2473medical equipment staff who participate in the training of
2474physician office staff for the use of nebulizers, including
2475cleaning, warranty, and special needs of patients.
2476     c.  The physician's office must have documented the
2477training and competency of any staff member who initiates the
2478delivery of nebulizers to patients. The durable medical
2479equipment provider must maintain copies of all physician office
2481     d.  The physician's office must maintain inventory records
2482of stored nebulizers, including documentation of the durable
2483medical equipment provider source.
2484     e.  A physician contracted with a Medicaid durable medical
2485equipment provider may not have a financial relationship with
2486that provider or receive any financial gain from the delivery of
2487nebulizers to patients.
2488     4.  Providers must have a physical business location and a
2489functional landline business phone. The location must be within
2490the state or not more than 50 miles from the Florida state line.
2491The agency may make exceptions for providers of durable medical
2492equipment or supplies not otherwise available from other
2493enrolled providers located within the state.
2494     5.  Physical business locations must be clearly identified
2495as a business that furnishes durable medical equipment or
2496medical supplies by signage that can be read from 20 feet away.
2497The location must be readily accessible to the public during
2498normal, posted business hours and must operate at least 5 hours
2499per day and at least 5 days per week, with the exception of
2500scheduled and posted holidays. The location may not be located
2501within or at the same numbered street address as another
2502enrolled Medicaid durable medical equipment or medical supply
2503provider or as an enrolled Medicaid pharmacy that is also
2504enrolled as a durable medical equipment provider. A licensed
2505orthotist or prosthetist that provides only orthotic or
2506prosthetic devices as a Medicaid durable medical equipment
2507provider is exempt from this paragraph.
2508     6.  Providers must maintain a stock of durable medical
2509equipment and medical supplies on site that is readily available
2510to meet the needs of the durable medical equipment business
2511location's customers.
2512     7.  Providers must provide a surety bond of $50,000 for
2513each provider location, up to a maximum of 5 bonds statewide or
2514an aggregate bond of $250,000 statewide, as identified by
2515Federal Employer Identification Number. Providers who post a
2516statewide or an aggregate bond must identify all of their
2517locations in any Medicaid durable medical equipment and medical
2518supply provider enrollment application or bond renewal. Each
2519provider location's surety bond must be renewed annually and the
2520provider must submit proof of renewal even if the original bond
2521is a continuous bond. A licensed orthotist or prosthetist that
2522provides only orthotic or prosthetic devices as a Medicaid
2523durable medical equipment provider is exempt from the provisions
2524in this paragraph.
2525     8.  Providers must obtain a level 2 background screening,
2526in accordance with chapter 435 and s. 408.809, for each provider
2527employee in direct contact with or providing direct services to
2528recipients of durable medical equipment and medical supplies in
2529their homes. This requirement includes, but is not limited to,
2530repair and service technicians, fitters, and delivery staff. The
2531provider shall pay for the cost of the background screening.
2532     9.  The following providers are exempt from subparagraphs
25331. and 7.:
2534     a.  Durable medical equipment providers owned and operated
2535by a government entity.
2536     b.  Durable medical equipment providers that are operating
2537within a pharmacy that is currently enrolled as a Medicaid
2538pharmacy provider.
2539     c.  Active, Medicaid-enrolled orthopedic physician groups,
2540primarily owned by physicians, which provide only orthotic and
2541prosthetic devices.
2542     (46)(49)  The agency shall contract with established
2543minority physician networks that provide services to
2544historically underserved minority patients. The networks must
2545provide cost-effective Medicaid services, comply with the
2546requirements to be a MediPass provider, and provide their
2547primary care physicians with access to data and other management
2548tools necessary to assist them in ensuring the appropriate use
2549of services, including inpatient hospital services and
2551     (a)  The agency shall provide for the development and
2552expansion of minority physician networks in each service area to
2553provide services to Medicaid recipients who are eligible to
2554participate under federal law and rules.
2555     (b)  The agency shall reimburse each minority physician
2556network as a fee-for-service provider, including the case
2557management fee for primary care, if any, or as a capitated rate
2558provider for Medicaid services. Any savings shall be shared with
2559the minority physician networks pursuant to the contract.
2560     (c)  For purposes of this subsection, the term "cost-
2561effective" means that a network's per-member, per-month costs to
2562the state, including, but not limited to, fee-for-service costs,
2563administrative costs, and case-management fees, if any, must be
2564no greater than the state's costs associated with contracts for
2565Medicaid services established under subsection (3), which shall
2566be actuarially adjusted for case mix, model, and service area.
2567The agency shall conduct actuarially sound audits adjusted for
2568case mix and model in order to ensure such cost-effectiveness
2569and shall annually publish the audit results on its Internet
2570website. Contracts established pursuant to this subsection which
2571are not cost-effective may not be renewed.
2572     (d)  The agency may apply for any federal waivers needed to
2573implement this subsection.
2575This subsection expires October 1, 2014.
2576     (47)(50)  To the extent permitted by federal law and as
2577allowed under s. 409.906, the agency shall provide reimbursement
2578for emergency mental health care services for Medicaid
2579recipients in crisis stabilization facilities licensed under s.
2580394.875 as long as those services are less expensive than the
2581same services provided in a hospital setting.
2582     (48)(51)  The agency shall work with the Agency for Persons
2583with Disabilities to develop a home and community-based waiver
2584to serve children and adults who are diagnosed with familial
2585dysautonomia or Riley-Day syndrome caused by a mutation of the
2586IKBKAP gene on chromosome 9. The agency shall seek federal
2587waiver approval and implement the approved waiver subject to the
2588availability of funds and any limitations provided in the
2589General Appropriations Act. The agency may adopt rules to
2590implement this waiver program.
2591     (49)(52)  The agency shall implement a program of all-
2592inclusive care for children. The program of all-inclusive care
2593for children shall be established to provide in-home hospice-
2594like support services to children diagnosed with a life-
2595threatening illness and enrolled in the Children's Medical
2596Services network to reduce hospitalizations as appropriate. The
2597agency, in consultation with the Department of Health, may
2598implement the program of all-inclusive care for children after
2599obtaining approval from the Centers for Medicare and Medicaid
2601     (50)(53)  Before seeking an amendment to the state plan for
2602purposes of implementing programs authorized by the Deficit
2603Reduction Act of 2005, the agency shall notify the Legislature.
2604     Section 14.  Section 409.91207, Florida Statutes, is
2606     Section 15.  Paragraphs (e), (l), (p), (w), and (dd) of
2607subsection (3) of section 409.91211, Florida Statutes, are
2608amended to read:
2609     409.91211  Medicaid managed care pilot program.-
2610     (3)  The agency shall have the following powers, duties,
2611and responsibilities with respect to the pilot program:
2612     (e)  To implement policies and guidelines for phasing in
2613financial risk for approved provider service networks that, for
2614purposes of this paragraph, include the Children's Medical
2615Services Network, over the period of the waiver and the
2616extension thereof. These policies and guidelines must include an
2617option for a provider service network to be paid fee-for-service
2618rates. For any provider service network established in a managed
2619care pilot area, the option to be paid fee-for-service rates
2620must include a savings-settlement mechanism that is consistent
2621with s. 409.912(42)(44). This model must be converted to a risk-
2622adjusted capitated rate by the beginning of the final year of
2623operation under the waiver extension, and may be converted
2624earlier at the option of the provider service network. Federally
2625qualified health centers may be offered an opportunity to accept
2626or decline a contract to participate in any provider network for
2627prepaid primary care services.
2628     (l)  To implement a system that prohibits capitated managed
2629care plans, their representatives, and providers employed by or
2630contracted with the capitated managed care plans from recruiting
2631persons eligible for or enrolled in Medicaid, from providing
2632inducements to Medicaid recipients to select a particular
2633capitated managed care plan, and from prejudicing Medicaid
2634recipients against other capitated managed care plans. The
2635system shall require the entity performing choice counseling to
2636determine if the recipient has made a choice of a plan or has
2637opted out because of duress, threats, payment to the recipient,
2638or incentives promised to the recipient by a third party. If the
2639choice counseling entity determines that the decision to choose
2640a plan was unlawfully influenced or a plan violated any of the
2641provisions of s. 409.912(20)(21), the choice counseling entity
2642shall immediately report the violation to the agency's program
2643integrity section for investigation. Verification of choice
2644counseling by the recipient shall include a stipulation that the
2645recipient acknowledges the provisions of this subsection.
2646     (p)  To implement standards for plan compliance, including,
2647but not limited to, standards for quality assurance and
2648performance improvement, standards for peer or professional
2649reviews, grievance policies, and policies for maintaining
2650program integrity. The agency shall develop a data-reporting
2651system, seek input from managed care plans in order to establish
2652requirements for patient-encounter reporting, and ensure that
2653the data reported is accurate and complete.
2654     1.  In performing the duties required under this section,
2655the agency shall work with managed care plans to establish a
2656uniform system to measure and monitor outcomes for a recipient
2657of Medicaid services.
2658     2.  The system shall use financial, clinical, and other
2659criteria based on pharmacy, medical services, and other data
2660that is related to the provision of Medicaid services,
2661including, but not limited to:
2662     a.  The Health Plan Employer Data and Information Set
2663(HEDIS) or measures that are similar to HEDIS.
2664     b.  Member satisfaction.
2665     c.  Provider satisfaction.
2666     d.  Report cards on plan performance and best practices.
2667     e.  Compliance with the requirements for prompt payment of
2668claims under ss. 627.613, 641.3155, and 641.513.
2669     f.  Utilization and quality data for the purpose of
2670ensuring access to medically necessary services, including
2671underutilization or inappropriate denial of services.
2672     3.  The agency shall require the managed care plans that
2673have contracted with the agency to establish a quality assurance
2674system that incorporates the provisions of s. 409.912(26)(27)
2675and any standards, rules, and guidelines developed by the
2677     4.  The agency shall establish an encounter database in
2678order to compile data on health services rendered by health care
2679practitioners who provide services to patients enrolled in
2680managed care plans in the demonstration sites. The encounter
2681database shall:
2682     a.  Collect the following for each type of patient
2683encounter with a health care practitioner or facility,
2685     (I)  The demographic characteristics of the patient.
2686     (II)  The principal, secondary, and tertiary diagnosis.
2687     (III)  The procedure performed.
2688     (IV)  The date and location where the procedure was
2690     (V)  The payment for the procedure, if any.
2691     (VI)  If applicable, the health care practitioner's
2692universal identification number.
2693     (VII)  If the health care practitioner rendering the
2694service is a dependent practitioner, the modifiers appropriate
2695to indicate that the service was delivered by the dependent
2697     b.  Collect appropriate information relating to
2698prescription drugs for each type of patient encounter.
2699     c.  Collect appropriate information related to health care
2700costs and utilization from managed care plans participating in
2701the demonstration sites.
2702     5.  To the extent practicable, when collecting the data the
2703agency shall use a standardized claim form or electronic
2704transfer system that is used by health care practitioners,
2705facilities, and payors.
2706     6.  Health care practitioners and facilities in the
2707demonstration sites shall electronically submit, and managed
2708care plans participating in the demonstration sites shall
2709electronically receive, information concerning claims payments
2710and any other information reasonably related to the encounter
2711database using a standard format as required by the agency.
2712     7.  The agency shall establish reasonable deadlines for
2713phasing in the electronic transmittal of full encounter data.
2714     8.  The system must ensure that the data reported is
2715accurate and complete.
2716     (w)  To implement procedures to minimize the risk of
2717Medicaid fraud and abuse in all plans operating in the Medicaid
2718managed care pilot program authorized in this section.
2719     1.  The agency shall ensure that applicable provisions of
2720this chapter and chapters 414, 626, 641, and 932 which relate to
2721Medicaid fraud and abuse are applied and enforced at the
2722demonstration project sites.
2723     2.  Providers must have the certification, license, and
2724credentials that are required by law and waiver requirements.
2725     3.  The agency shall ensure that the plan is in compliance
2726with s. 409.912(20) and (21) and (22).
2727     4.  The agency shall require that each plan establish
2728functions and activities governing program integrity in order to
2729reduce the incidence of fraud and abuse. Plans must report
2730instances of fraud and abuse pursuant to chapter 641.
2731     5.  The plan shall have written administrative and
2732management arrangements or procedures, including a mandatory
2733compliance plan, which are designed to guard against fraud and
2734abuse. The plan shall designate a compliance officer who has
2735sufficient experience in health care.
2736     6.a.  The agency shall require all managed care plan
2737contractors in the pilot program to report all instances of
2738suspected fraud and abuse. A failure to report instances of
2739suspected fraud and abuse is a violation of law and subject to
2740the penalties provided by law.
2741     b.  An instance of fraud and abuse in the managed care
2742plan, including, but not limited to, defrauding the state health
2743care benefit program by misrepresentation of fact in reports,
2744claims, certifications, enrollment claims, demographic
2745statistics, or patient-encounter data; misrepresentation of the
2746qualifications of persons rendering health care and ancillary
2747services; bribery and false statements relating to the delivery
2748of health care; unfair and deceptive marketing practices; and
2749false claims actions in the provision of managed care, is a
2750violation of law and subject to the penalties provided by law.
2751     c.  The agency shall require that all contractors make all
2752files and relevant billing and claims data accessible to state
2753regulators and investigators and that all such data is linked
2754into a unified system to ensure consistent reviews and
2756     (dd)  To implement service delivery mechanisms within a
2757specialty plan in area 10 to provide behavioral health care
2758services to Medicaid-eligible children whose cases are open for
2759child welfare services in the HomeSafeNet system. These services
2760must be coordinated with community-based care providers as
2761specified in s. 409.1671, where available, and be sufficient to
2762meet the developmental, behavioral, and emotional needs of these
2763children. Children in area 10 who have an open case in the
2764HomeSafeNet system shall be enrolled into the specialty plan.
2765These service delivery mechanisms must be implemented no later
2766than July 1, 2011, in AHCA area 10 in order for the children in
2767AHCA area 10 to remain exempt from the statewide plan under s.
2768409.912(4)(b)5.8. An administrative fee may be paid to the
2769specialty plan for the coordination of services based on the
2770receipt of the state share of that fee being provided through
2771intergovernmental transfers.
2772     Section 16.  Effective October 1, 2014, section 409.91211,
2773Florida Statutes, is repealed.
2774     Section 17.  Section 409.9122, Florida Statutes, is amended
2775to read:
2776     409.9122  Mandatory Medicaid managed care enrollment;
2777programs and procedures.-
2778     (1)  It is the intent of the Legislature that the MediPass
2779program be cost-effective, provide quality health care, and
2780improve access to health services, and that the program be
2781statewide. This subsection expires October 1, 2014.
2782     (2)(a)  The agency shall enroll in a managed care plan or
2783MediPass all Medicaid recipients, except those Medicaid
2784recipients who are: in an institution; enrolled in the Medicaid
2785medically needy program; or eligible for both Medicaid and
2786Medicare. Upon enrollment, individuals will be able to change
2787their managed care option during the 90-day opt out period
2788required by federal Medicaid regulations. The agency is
2789authorized to seek the necessary Medicaid state plan amendment
2790to implement this policy. However, to the extent permitted by
2791federal law, the agency may enroll in a managed care plan or
2792MediPass a Medicaid recipient who is exempt from mandatory
2793managed care enrollment, provided that:
2794     1.  The recipient's decision to enroll in a managed care
2795plan or MediPass is voluntary;
2796     2.  If the recipient chooses to enroll in a managed care
2797plan, the agency has determined that the managed care plan
2798provides specific programs and services which address the
2799special health needs of the recipient; and
2800     3.  The agency receives any necessary waivers from the
2801federal Centers for Medicare and Medicaid Services.
2803The agency shall develop rules to establish policies by which
2804exceptions to the mandatory managed care enrollment requirement
2805may be made on a case-by-case basis. The rules shall include the
2806specific criteria to be applied when making a determination as
2807to whether to exempt a recipient from mandatory enrollment in a
2808managed care plan or MediPass. School districts participating in
2809the certified school match program pursuant to ss. 409.908(21)
2810and 1011.70 shall be reimbursed by Medicaid, subject to the
2811limitations of s. 1011.70(1), for a Medicaid-eligible child
2812participating in the services as authorized in s. 1011.70, as
2813provided for in s. 409.9071, regardless of whether the child is
2814enrolled in MediPass or a managed care plan. Managed care plans
2815shall make a good faith effort to execute agreements with school
2816districts regarding the coordinated provision of services
2817authorized under s. 1011.70. County health departments
2818delivering school-based services pursuant to ss. 381.0056 and
2819381.0057 shall be reimbursed by Medicaid for the federal share
2820for a Medicaid-eligible child who receives Medicaid-covered
2821services in a school setting, regardless of whether the child is
2822enrolled in MediPass or a managed care plan. Managed care plans
2823shall make a good faith effort to execute agreements with county
2824health departments regarding the coordinated provision of
2825services to a Medicaid-eligible child. To ensure continuity of
2826care for Medicaid patients, the agency, the Department of
2827Health, and the Department of Education shall develop procedures
2828for ensuring that a student's managed care plan or MediPass
2829provider receives information relating to services provided in
2830accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2831     (b)  A Medicaid recipient shall not be enrolled in or
2832assigned to a managed care plan or MediPass unless the managed
2833care plan or MediPass has complied with the quality-of-care
2834standards specified in paragraphs (3)(a) and (b), respectively.
2835     (c)  Medicaid recipients shall have a choice of managed
2836care plans or MediPass. The Agency for Health Care
2837Administration, the Department of Health, the Department of
2838Children and Family Services, and the Department of Elderly
2839Affairs shall cooperate to ensure that each Medicaid recipient
2840receives clear and easily understandable information that meets
2841the following requirements:
2842     1.  Explains the concept of managed care, including
2844     2.  Provides information on the comparative performance of
2845managed care plans and MediPass in the areas of quality,
2846credentialing, preventive health programs, network size and
2847availability, and patient satisfaction.
2848     3.  Explains where additional information on each managed
2849care plan and MediPass in the recipient's area can be obtained.
2850     4.  Explains that recipients have the right to choose their
2851managed care coverage at the time they first enroll in Medicaid
2852and again at regular intervals set by the agency. However, if a
2853recipient does not choose a managed care plan or MediPass, the
2854agency will assign the recipient to a managed care plan or
2855MediPass according to the criteria specified in this section.
2856     5.  Explains the recipient's right to complain, file a
2857grievance, or change managed care plans or MediPass providers if
2858the recipient is not satisfied with the managed care plan or
2860     (d)  The agency shall develop a mechanism for providing
2861information to Medicaid recipients for the purpose of making a
2862managed care plan or MediPass selection. Examples of such
2863mechanisms may include, but not be limited to, interactive
2864information systems, mailings, and mass marketing materials.
2865Managed care plans and MediPass providers are prohibited from
2866providing inducements to Medicaid recipients to select their
2867plans or from prejudicing Medicaid recipients against other
2868managed care plans or MediPass providers.
2869     (e)  Medicaid recipients who are already enrolled in a
2870managed care plan or MediPass shall be offered the opportunity
2871to change managed care plans or MediPass providers on a
2872staggered basis, as defined by the agency. All Medicaid
2873recipients shall have 30 days in which to make a choice of
2874managed care plans or MediPass providers. Those Medicaid
2875recipients who do not make a choice shall be assigned in
2876accordance with paragraph (f). To facilitate continuity of care,
2877for a Medicaid recipient who is also a recipient of Supplemental
2878Security Income (SSI), prior to assigning the SSI recipient to a
2879managed care plan or MediPass, the agency shall determine
2880whether the SSI recipient has an ongoing relationship with a
2881MediPass provider or managed care plan, and if so, the agency
2882shall assign the SSI recipient to that MediPass provider or
2883managed care plan. Those SSI recipients who do not have such a
2884provider relationship shall be assigned to a managed care plan
2885or MediPass provider in accordance with paragraph (f).
2886     (f)  If a Medicaid recipient does not choose a managed care
2887plan or MediPass provider, the agency shall assign the Medicaid
2888recipient to a managed care plan or MediPass provider. Medicaid
2889recipients eligible for managed care plan enrollment who are
2890subject to mandatory assignment but who fail to make a choice
2891shall be assigned to managed care plans until an enrollment of
289235 percent in MediPass and 65 percent in managed care plans, of
2893all those eligible to choose managed care, is achieved. Once
2894this enrollment is achieved, the assignments shall be divided in
2895order to maintain an enrollment in MediPass and managed care
2896plans which is in a 35 percent and 65 percent proportion,
2897respectively. Thereafter, assignment of Medicaid recipients who
2898fail to make a choice shall be based proportionally on the
2899preferences of recipients who have made a choice in the previous
2900period. Such proportions shall be revised at least quarterly to
2901reflect an update of the preferences of Medicaid recipients. The
2902agency shall disproportionately assign Medicaid-eligible
2903recipients who are required to but have failed to make a choice
2904of managed care plan or MediPass, including children, and who
2905would be assigned to the MediPass program to the children's
2906networks as described in s. 409.912(4)(g), Children's Medical
2907Services Network as defined in s. 391.021, exclusive provider
2908organizations, provider service networks, minority physician
2909networks, and pediatric emergency department diversion programs
2910authorized by this chapter or the General Appropriations Act, in
2911such manner as the agency deems appropriate, until the agency
2912has determined that the networks and programs have sufficient
2913numbers to be operated economically. For purposes of this
2914paragraph, when referring to assignment, the term "managed care
2915plans" includes health maintenance organizations, exclusive
2916provider organizations, provider service networks, minority
2917physician networks, Children's Medical Services Network, and
2918pediatric emergency department diversion programs authorized by
2919this chapter or the General Appropriations Act. When making
2920assignments, the agency shall take into account the following
2922     1.  A managed care plan has sufficient network capacity to
2923meet the need of members.
2924     2.  The managed care plan or MediPass has previously
2925enrolled the recipient as a member, or one of the managed care
2926plan's primary care providers or MediPass providers has
2927previously provided health care to the recipient.
2928     3.  The agency has knowledge that the member has previously
2929expressed a preference for a particular managed care plan or
2930MediPass provider as indicated by Medicaid fee-for-service
2931claims data, but has failed to make a choice.
2932     4.  The managed care plan's or MediPass primary care
2933providers are geographically accessible to the recipient's
2935     (g)  When more than one managed care plan or MediPass
2936provider meets the criteria specified in paragraph (f), the
2937agency shall make recipient assignments consecutively by family
2939     (h)  The agency may not engage in practices that are
2940designed to favor one managed care plan over another or that are
2941designed to influence Medicaid recipients to enroll in MediPass
2942rather than in a managed care plan or to enroll in a managed
2943care plan rather than in MediPass. This subsection does not
2944prohibit the agency from reporting on the performance of
2945MediPass or any managed care plan, as measured by performance
2946criteria developed by the agency.
2947     (i)  After a recipient has made his or her selection or has
2948been enrolled in a managed care plan or MediPass, the recipient
2949shall have 90 days to exercise the opportunity to voluntarily
2950disenroll and select another managed care plan or MediPass.
2951After 90 days, no further changes may be made except for good
2952cause. Good cause includes, but is not limited to, poor quality
2953of care, lack of access to necessary specialty services, an
2954unreasonable delay or denial of service, or fraudulent
2955enrollment. The agency shall develop criteria for good cause
2956disenrollment for chronically ill and disabled populations who
2957are assigned to managed care plans if more appropriate care is
2958available through the MediPass program. The agency must make a
2959determination as to whether cause exists. However, the agency
2960may require a recipient to use the managed care plan's or
2961MediPass grievance process prior to the agency's determination
2962of cause, except in cases in which immediate risk of permanent
2963damage to the recipient's health is alleged. The grievance
2964process, when utilized, must be completed in time to permit the
2965recipient to disenroll by the first day of the second month
2966after the month the disenrollment request was made. If the
2967managed care plan or MediPass, as a result of the grievance
2968process, approves an enrollee's request to disenroll, the agency
2969is not required to make a determination in the case. The agency
2970must make a determination and take final action on a recipient's
2971request so that disenrollment occurs no later than the first day
2972of the second month after the month the request was made. If the
2973agency fails to act within the specified timeframe, the
2974recipient's request to disenroll is deemed to be approved as of
2975the date agency action was required. Recipients who disagree
2976with the agency's finding that cause does not exist for
2977disenrollment shall be advised of their right to pursue a
2978Medicaid fair hearing to dispute the agency's finding.
2979     (j)  The agency shall apply for a federal waiver from the
2980Centers for Medicare and Medicaid Services to lock eligible
2981Medicaid recipients into a managed care plan or MediPass for 12
2982months after an open enrollment period. After 12 months'
2983enrollment, a recipient may select another managed care plan or
2984MediPass provider. However, nothing shall prevent a Medicaid
2985recipient from changing primary care providers within the
2986managed care plan or MediPass program during the 12-month
2988     (k)  When a Medicaid recipient does not choose a managed
2989care plan or MediPass provider, the agency shall assign the
2990Medicaid recipient to a managed care plan, except in those
2991counties in which there are fewer than two managed care plans
2992accepting Medicaid enrollees, in which case assignment shall be
2993to a managed care plan or a MediPass provider. Medicaid
2994recipients in counties with fewer than two managed care plans
2995accepting Medicaid enrollees who are subject to mandatory
2996assignment but who fail to make a choice shall be assigned to
2997managed care plans until an enrollment of 35 percent in MediPass
2998and 65 percent in managed care plans, of all those eligible to
2999choose managed care, is achieved. Once that enrollment is
3000achieved, the assignments shall be divided in order to maintain
3001an enrollment in MediPass and managed care plans which is in a
300235 percent and 65 percent proportion, respectively. For purposes
3003of this paragraph, when referring to assignment, the term
3004"managed care plans" includes exclusive provider organizations,
3005provider service networks, Children's Medical Services Network,
3006minority physician networks, and pediatric emergency department
3007diversion programs authorized by this chapter or the General
3008Appropriations Act. When making assignments, the agency shall
3009take into account the following criteria:
3010     1.  A managed care plan has sufficient network capacity to
3011meet the need of members.
3012     2.  The managed care plan or MediPass has previously
3013enrolled the recipient as a member, or one of the managed care
3014plan's primary care providers or MediPass providers has
3015previously provided health care to the recipient.
3016     3.  The agency has knowledge that the member has previously
3017expressed a preference for a particular managed care plan or
3018MediPass provider as indicated by Medicaid fee-for-service
3019claims data, but has failed to make a choice.
3020     4.  The managed care plan's or MediPass primary care
3021providers are geographically accessible to the recipient's
3023     5.  The agency has authority to make mandatory assignments
3024based on quality of service and performance of managed care
3026     (l)  Notwithstanding the provisions of chapter 287, the
3027agency may, at its discretion, renew cost-effective contracts
3028for choice counseling services once or more for such periods as
3029the agency may decide. However, all such renewals may not
3030combine to exceed a total period longer than the term of the
3031original contract.
3033This subsection expires October 1, 2014.
3034     (3)(a)  The agency shall establish quality-of-care
3035standards for managed care plans. These standards shall be based
3036upon, but are not limited to:
3037     1.  Compliance with the accreditation requirements as
3038provided in s. 641.512.
3039     2.  Compliance with Early and Periodic Screening,
3040Diagnosis, and Treatment screening requirements.
3041     3.  The percentage of voluntary disenrollments.
3042     4.  Immunization rates.
3043     5.  Standards of the National Committee for Quality
3044Assurance and other approved accrediting bodies.
3045     6.  Recommendations of other authoritative bodies.
3046     7.  Specific requirements of the Medicaid program, or
3047standards designed to specifically assist the unique needs of
3048Medicaid recipients.
3049     8.  Compliance with the health quality improvement system
3050as established by the agency, which incorporates standards and
3051guidelines developed by the Medicaid Bureau of the Health Care
3052Financing Administration as part of the quality assurance reform
3054     (b)  For the MediPass program, the agency shall establish
3055standards which are based upon, but are not limited to:
3056     1.  Quality-of-care standards which are comparable to those
3057required of managed care plans.
3058     2.  Credentialing standards for MediPass providers.
3059     3.  Compliance with Early and Periodic Screening,
3060Diagnosis, and Treatment screening requirements.
3061     4.  Immunization rates.
3062     5.  Specific requirements of the Medicaid program, or
3063standards designed to specifically assist the unique needs of
3064Medicaid recipients.
3066This subsection expires October 1, 2014.
3067     (4)(a)  Each female recipient may select as her primary
3068care provider an obstetrician/gynecologist who has agreed to
3069participate as a MediPass primary care case manager.
3070     (b)  The agency shall establish a complaints and grievance
3071process to assist Medicaid recipients enrolled in the MediPass
3072program to resolve complaints and grievances. The agency shall
3073investigate reports of quality-of-care grievances which remain
3074unresolved to the satisfaction of the enrollee.
3076This subsection expires October 1, 2014.
3077     (5)(a)  The agency shall work cooperatively with the Social
3078Security Administration to identify beneficiaries who are
3079jointly eligible for Medicare and Medicaid and shall develop
3080cooperative programs to encourage these beneficiaries to enroll
3081in a Medicare participating health maintenance organization or
3082prepaid health plans.
3083     (b)  The agency shall work cooperatively with the
3084Department of Elderly Affairs to assess the potential cost-
3085effectiveness of providing MediPass to beneficiaries who are
3086jointly eligible for Medicare and Medicaid on a voluntary choice
3087basis. If the agency determines that enrollment of these
3088beneficiaries in MediPass has the potential for being cost-
3089effective for the state, the agency shall offer MediPass to
3090these beneficiaries on a voluntary choice basis in the counties
3091where MediPass operates.
3093This subsection expires October 1, 2014.
3094     (6)  MediPass enrolled recipients may receive up to 10
3095visits of reimbursable services by participating Medicaid
3096physicians licensed under chapter 460 and up to four visits of
3097reimbursable services by participating Medicaid physicians
3098licensed under chapter 461. Any further visits must be by prior
3099authorization by the MediPass primary care provider. However,
3100nothing in this subsection may be construed to increase the
3101total number of visits or the total amount of dollars per year
3102per person under current Medicaid rules, unless otherwise
3103provided for in the General Appropriations Act. This subsection
3104expires October 1, 2014.
3105     (7)  The agency shall investigate the feasibility of
3106developing managed care plan and MediPass options for the
3107following groups of Medicaid recipients:
3108     (a)  Pregnant women and infants.
3109     (b)  Elderly and disabled recipients, especially those who
3110are at risk of nursing home placement.
3111     (c)  Persons with developmental disabilities.
3112     (d)  Qualified Medicare beneficiaries.
3113     (e)  Adults who have chronic, high-cost medical conditions.
3114     (f)  Adults and children who have mental health problems.
3115     (g)  Other recipients for whom managed care plans and
3116MediPass offer the opportunity of more cost-effective care and
3117greater access to qualified providers.
3118     (8)(a)  The agency shall encourage the development of
3119public and private partnerships to foster the growth of health
3120maintenance organizations and prepaid health plans that will
3121provide high-quality health care to Medicaid recipients.
3122     (b)  Subject to the availability of moneys and any
3123limitations established by the General Appropriations Act or
3124chapter 216, the agency is authorized to enter into contracts
3125with traditional providers of health care to low-income persons
3126to assist such providers with the technical aspects of
3127cooperatively developing Medicaid prepaid health plans.
3128     1.  The agency may contract with disproportionate share
3129hospitals, county health departments, federally initiated or
3130federally funded community health centers, and counties that
3131operate either a hospital or a community clinic.
3132     2.  A contract may not be for more than $100,000 per year,
3133and no contract may be extended with any particular provider for
3134more than 2 years. The contract is intended only as seed or
3135development funding and requires a commitment from the
3136interested party.
3137     3.  A contract must require participation by at least one
3138community health clinic and one disproportionate share hospital.
3139     (7)(9)(a)  The agency shall develop and implement a
3140comprehensive plan to ensure that recipients are adequately
3141informed of their choices and rights under all Medicaid managed
3142care programs and that Medicaid managed care programs meet
3143acceptable standards of quality in patient care, patient
3144satisfaction, and financial solvency.
3145     (b)  The agency shall provide adequate means for informing
3146patients of their choice and rights under a managed care plan at
3147the time of eligibility determination.
3148     (c)  The agency shall require managed care plans and
3149MediPass providers to demonstrate and document plans and
3150activities, as defined by rule, including outreach and followup,
3151undertaken to ensure that Medicaid recipients receive the health
3152care service to which they are entitled.
3154This subsection expires October 1, 2014.
3155     (8)(10)  The agency shall consult with Medicaid consumers
3156and their representatives on an ongoing basis regarding
3157measurements of patient satisfaction, procedures for resolving
3158patient grievances, standards for ensuring quality of care,
3159mechanisms for providing patient access to services, and
3160policies affecting patient care. This subsection expires October
31611, 2014.
3162     (9)(11)  The agency may extend eligibility for Medicaid
3163recipients enrolled in licensed and accredited health
3164maintenance organizations for the duration of the enrollment
3165period or for 6 months, whichever is earlier, provided the
3166agency certifies that such an offer will not increase state
3167expenditures. This subsection expires October 1, 2013.
3168     (10)(12)  A managed care plan that has a Medicaid contract
3169shall at least annually review each primary care physician's
3170active patient load and shall ensure that additional Medicaid
3171recipients are not assigned to physicians who have a total
3172active patient load of more than 3,000 patients. As used in this
3173subsection, the term "active patient" means a patient who is
3174seen by the same primary care physician, or by a physician
3175assistant or advanced registered nurse practitioner under the
3176supervision of the primary care physician, at least three times
3177within a calendar year. Each primary care physician shall
3178annually certify to the managed care plan whether or not his or
3179her patient load exceeds the limits established under this
3180subsection and the managed care plan shall accept such
3181certification on face value as compliance with this subsection.
3182The agency shall accept the managed care plan's representations
3183that it is in compliance with this subsection based on the
3184certification of its primary care physicians, unless the agency
3185has an objective indication that access to primary care is being
3186compromised, such as receiving complaints or grievances relating
3187to access to care. If the agency determines that an objective
3188indication exists that access to primary care is being
3189compromised, it may verify the patient load certifications
3190submitted by the managed care plan's primary care physicians and
3191that the managed care plan is not assigning Medicaid recipients
3192to primary care physicians who have an active patient load of
3193more than 3,000 patients. This subsection expires October 1,
3195     (11)(13)  Effective July 1, 2003, the agency shall adjust
3196the enrollee assignment process of Medicaid managed prepaid
3197health plans for those Medicaid managed prepaid plans operating
3198in Miami-Dade County which have executed a contract with the
3199agency for a minimum of 8 consecutive years in order for the
3200Medicaid managed prepaid plan to maintain a minimum enrollment
3201level of 15,000 members per month. When assigning enrollees
3202pursuant to this subsection, the agency shall give priority to
3203providers that initially qualified under this subsection until
3204such providers reach and maintain an enrollment level of 15,000
3205members per month. A prepaid health plan that has a statewide
3206Medicaid enrollment of 25,000 or more members is not eligible
3207for enrollee assignments under this subsection. This subsection
3208expires October 1, 2014.
3209     (12)(14)  The agency shall include in its calculation of
3210the hospital inpatient component of a Medicaid health
3211maintenance organization's capitation rate any special payments,
3212including, but not limited to, upper payment limit or
3213disproportionate share hospital payments, made to qualifying
3214hospitals through the fee-for-service program. The agency may
3215seek federal waiver approval or state plan amendment as needed
3216to implement this adjustment.
3217     (13)  The agency shall develop a process to enable any
3218recipient with access to employer-sponsored health care coverage
3219to opt out of all eligible plans in the Medicaid program and to
3220use Medicaid financial assistance to pay for the recipient's
3221share of cost in any such employer-sponsored coverage.
3222Contingent on federal approval, the agency shall also enable
3223recipients with access to other insurance or related products
3224that provide access to health care services created pursuant to
3225state law, including any plan or product available pursuant to
3226the Florida Health Choices Program or any health exchange, to
3227opt out. The amount of financial assistance provided for each
3228recipient may not exceed the amount of the Medicaid premium that
3229would have been paid to a plan for that recipient.
3230     (14)  The agency shall maintain and operate the Medicaid
3231Encounter Data System to collect, process, store, and report on
3232covered services provided to all Florida Medicaid recipients
3233enrolled in prepaid managed care plans.
3234     (a)  Prepaid managed care plans shall submit encounter data
3235electronically in a format that complies with the Health
3236Insurance Portability and Accountability Act provisions for
3237electronic claims and in accordance with deadlines established
3238by the agency. Prepaid managed care plans must certify that the
3239data reported is accurate and complete.
3240     (b)  The agency is responsible for validating the data
3241submitted by the plans. The agency shall develop methods and
3242protocols for ongoing analysis of the encounter data that
3243adjusts for differences in characteristics of prepaid plan
3244enrollees to allow comparison of service utilization among plans
3245and against expected levels of use. The analysis shall be used
3246to identify possible cases of systemic underutilization or
3247denials of claims and inappropriate service utilization such as
3248higher-than-expected emergency department encounters. The
3249analysis shall provide periodic feedback to the plans and enable
3250the agency to establish corrective action plans when necessary.
3251One of the focus areas for the analysis shall be the use of
3252prescription drugs.
3253     (15)  The agency may establish a per-member, per-month
3254payment for Medicare Advantage Special Needs members that are
3255also eligible for Medicaid as a mechanism for meeting the
3256state's cost-sharing obligation. The agency may also develop a
3257per-member, per-month payment only for Medicaid-covered services
3258for which the state is responsible. The agency shall develop a
3259mechanism to ensure that such per-member, per-month payment
3260enhances the value to the state and enrolled members by limiting
3261cost sharing, enhances the scope of Medicare supplemental
3262benefits that are equal to or greater than Medicaid coverage for
3263select services, and improves care coordination.
3264     (16)  The agency shall establish, and managed care plans
3265shall use, a uniform method of accounting for and reporting
3266medical and nonmedical costs. The agency shall make such
3267information available to the public.
3268     (17)  The agency may, on a case-by-case basis, exempt a
3269recipient from mandatory enrollment in a managed care plan when
3270the recipient has a unique, time-limited disease or condition-
3271related circumstance and managed care enrollment will interfere
3272with ongoing care because the recipient's provider does not
3273participate in the managed care plans available in the
3274recipient's area.
3275     (18)  The agency shall contract with a single provider
3276service network to function as a third-party administrator and
3277managing entity for the MediPass program in all counties with
3278fewer than two prepaid plans. The contractor may earn an
3279administrative fee, if the fee is less than any savings
3280determined by the reconciliation process pursuant to s.
3281409.912(4)(d)1. This subsection expires October 1, 2014, or upon
3282full implementation of the managed medical assistance program,
3283whichever is sooner.
3284     (19)  Subject to federal approval, the agency shall
3285contract with a single provider service network to function as a
3286third-party administrator and managing entity for the Medically
3287Needy program in all counties. The contractor shall provide care
3288coordination and utilization management in order to achieve more
3289cost-effective services for Medically Needy enrollees. To
3290facilitate the care management functions of the provider service
3291network, enrollment in the network shall be for a continuous 6-
3292month period or until the end of the contract between the
3293provider service network and the agency, whichever is sooner.
3294Beginning the second month after the determination of
3295eligibility, the contractor may collect a monthly premium from
3296each Medically Needy recipient provided the premium does not
3297exceed the enrollee's share of cost as determined by the
3298Department of Children and Family Services. The contractor must
3299provide a 90-day grace period before disenrolling a Medically
3300Needy recipient for failure to pay premiums. The contractor may
3301earn an administrative fee, if the fee is less than any savings
3302determined by the reconciliation process pursuant to s.
3303409.912(4)(d)1. Premium revenue collected from the recipients
3304shall be deducted from the contractor's earned savings. This
3305subsection expires October 1, 2014, or upon full implementation
3306of the managed medical assistance program, whichever is sooner.
3307     Section 18.  Subsection (15) of section 430.04, Florida
3308Statutes, is amended to read:
3309     430.04  Duties and responsibilities of the Department of
3310Elderly Affairs.-The Department of Elderly Affairs shall:
3311     (15)  Administer all Medicaid waivers and programs relating
3312to elders and their appropriations. The waivers include, but are
3313not limited to:
3314     (a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3315established in s. 430.502(7), (8), and (9).
3316     (a)(b)  The Assisted Living for the Frail Elderly Waiver.
3317     (b)(c)  The Aged and Disabled Adult Waiver.
3318     (c)(d)  The Adult Day Health Care Waiver.
3319     (d)(e)  The Consumer-Directed Care Plus Program as defined
3320in s. 409.221.
3321     (e)(f)  The Program of All-inclusive Care for the Elderly.
3322     (f)(g)  The Long-Term Care Community-Based Diversion Pilot
3323Project as described in s. 430.705.
3324     (g)(h)  The Channeling Services Waiver for Frail Elders.
3326The department shall develop a transition plan for recipients
3327receiving services in long-term care Medicaid waivers for elders
3328or disabled adults on the date eligible plans become available
3329in each recipient's region defined in s. 409.981(2) to enroll
3330those recipients in eligible plans. This subsection expires
3331October 1, 2014.
3332     Section 19.  Section 430.2053, Florida Statutes, is amended
3333to read:
3334     430.2053  Aging resource centers.-
3335     (1)  The department, in consultation with the Agency for
3336Health Care Administration and the Department of Children and
3337Family Services, shall develop pilot projects for aging resource
3338centers. By October 31, 2004, the department, in consultation
3339with the agency and the Department of Children and Family
3340Services, shall develop an implementation plan for aging
3341resource centers and submit the plan to the Governor, the
3342President of the Senate, and the Speaker of the House of
3343Representatives. The plan must include qualifications for
3344designation as a center, the functions to be performed by each
3345center, and a process for determining that a current area agency
3346on aging is ready to assume the functions of an aging resource
3348     (2)  Each area agency on aging shall develop, in
3349consultation with the existing community care for the elderly
3350lead agencies within their planning and service areas, a
3351proposal that describes the process the area agency on aging
3352intends to undertake to transition to an aging resource center
3353prior to July 1, 2005, and that describes the area agency's
3354compliance with the requirements of this section. The proposals
3355must be submitted to the department prior to December 31, 2004.
3356The department shall evaluate all proposals for readiness and,
3357prior to March 1, 2005, shall select three area agencies on
3358aging which meet the requirements of this section to begin the
3359transition to aging resource centers. Those area agencies on
3360aging which are not selected to begin the transition to aging
3361resource centers shall, in consultation with the department and
3362the existing community care for the elderly lead agencies within
3363their planning and service areas, amend their proposals as
3364necessary and resubmit them to the department prior to July 1,
33652005. The department may transition additional area agencies to
3366aging resource centers as it determines that area agencies are
3367in compliance with the requirements of this section.
3368     (3)  The Auditor General and the Office of Program Policy
3369Analysis and Government Accountability (OPPAGA) shall jointly
3370review and assess the department's process for determining an
3371area agency's readiness to transition to an aging resource
3373     (a)  The review must, at a minimum, address the
3374appropriateness of the department's criteria for selection of an
3375area agency to transition to an aging resource center, the
3376instruments applied, the degree to which the department
3377accurately determined each area agency's compliance with the
3378readiness criteria, the quality of the technical assistance
3379provided by the department to an area agency in correcting any
3380weaknesses identified in the readiness assessment, and the
3381degree to which each area agency overcame any identified
3383     (b)  Reports of these reviews must be submitted to the
3384appropriate substantive and appropriations committees in the
3385Senate and the House of Representatives on March 1 and September
33861 of each year until full transition to aging resource centers
3387has been accomplished statewide, except that the first report
3388must be submitted by February 1, 2005, and must address all
3389readiness activities undertaken through December 31, 2004. The
3390perspectives of all participants in this review process must be
3391included in each report.
3392     (2)(4)  The purposes of an aging resource center shall be:
3393     (a)  To provide Florida's elders and their families with a
3394locally focused, coordinated approach to integrating information
3395and referral for all available services for elders with the
3396eligibility determination entities for state and federally
3397funded long-term-care services.
3398     (b)  To provide for easier access to long-term-care
3399services by Florida's elders and their families by creating
3400multiple access points to the long-term-care network that flow
3401through one established entity with wide community recognition.
3402     (3)(5)  The duties of an aging resource center are to:
3403     (a)  Develop referral agreements with local community
3404service organizations, such as senior centers, existing elder
3405service providers, volunteer associations, and other similar
3406organizations, to better assist clients who do not need or do
3407not wish to enroll in programs funded by the department or the
3408agency. The referral agreements must also include a protocol,
3409developed and approved by the department, which provides
3410specific actions that an aging resource center and local
3411community service organizations must take when an elder or an
3412elder's representative seeking information on long-term-care
3413services contacts a local community service organization prior
3414to contacting the aging resource center. The protocol shall be
3415designed to ensure that elders and their families are able to
3416access information and services in the most efficient and least
3417cumbersome manner possible.
3418     (b)  Provide an initial screening of all clients who
3419request long-term-care services to determine whether the person
3420would be most appropriately served through any combination of
3421federally funded programs, state-funded programs, locally funded
3422or community volunteer programs, or private funding for
3424     (c)  Determine eligibility for the programs and services
3425listed in subsection (9) (11) for persons residing within the
3426geographic area served by the aging resource center and
3427determine a priority ranking for services which is based upon
3428the potential recipient's frailty level and likelihood of
3429institutional placement without such services.
3430     (d)  Manage the availability of financial resources for the
3431programs and services listed in subsection (9) (11) for persons
3432residing within the geographic area served by the aging resource
3434     (e)  When financial resources become available, refer a
3435client to the most appropriate entity to begin receiving
3436services. The aging resource center shall make referrals to lead
3437agencies for service provision that ensure that individuals who
3438are vulnerable adults in need of services pursuant to s.
3439415.104(3)(b), or who are victims of abuse, neglect, or
3440exploitation in need of immediate services to prevent further
3441harm and are referred by the adult protective services program,
3442are given primary consideration for receiving community-care-
3443for-the-elderly services in compliance with the requirements of
3444s. 430.205(5)(a) and that other referrals for services are in
3445compliance with s. 430.205(5)(b).
3446     (f)  Convene a work group to advise in the planning,
3447implementation, and evaluation of the aging resource center. The
3448work group shall be comprised of representatives of local
3449service providers, Alzheimer's Association chapters, housing
3450authorities, social service organizations, advocacy groups,
3451representatives of clients receiving services through the aging
3452resource center, and any other persons or groups as determined
3453by the department. The aging resource center, in consultation
3454with the work group, must develop annual program improvement
3455plans that shall be submitted to the department for
3456consideration. The department shall review each annual
3457improvement plan and make recommendations on how to implement
3458the components of the plan.
3459     (g)  Enhance the existing area agency on aging in each
3460planning and service area by integrating, either physically or
3461virtually, the staff and services of the area agency on aging
3462with the staff of the department's local CARES Medicaid nursing
3463home preadmission screening unit and a sufficient number of
3464staff from the Department of Children and Family Services'
3465Economic Self-Sufficiency Unit necessary to determine the
3466financial eligibility for all persons age 60 and older residing
3467within the area served by the aging resource center that are
3468seeking Medicaid services, Supplemental Security Income, and
3469food assistance.
3470     (h)  Assist clients who request long-term care services in
3471being evaluated for eligibility for enrollment in the Medicaid
3472long-term care managed care program as eligible plans become
3473available in each of the regions pursuant to s. 409.981(2).
3474     (i)  Provide choice counseling for the Medicaid long-term
3475care managed care program by integrating, either physically or
3476virtually, choice counseling staff and services as eligible
3477plans become available in each of the regions pursuant to s.
3478409.981(2). Pursuant to s. 409.984(1), the agency may contract
3479directly with the aging resource center to provide choice
3480counseling services or may contract with another vendor if the
3481aging resource center does not choose to provide such services.
3482     (j)  Assist Medicaid recipients enrolled in the Medicaid
3483long-term care managed care program with informally resolving
3484grievances with a managed care network and assist Medicaid
3485recipients in accessing the managed care network's formal
3486grievance process as eligible plans become available in each of
3487the regions defined in s. 409.981(2).
3488     (4)(6)  The department shall select the entities to become
3489aging resource centers based on each entity's readiness and
3490ability to perform the duties listed in subsection (3) (5) and
3491the entity's:
3492     (a)  Expertise in the needs of each target population the
3493center proposes to serve and a thorough knowledge of the
3494providers that serve these populations.
3495     (b)  Strong connections to service providers, volunteer
3496agencies, and community institutions.
3497     (c)  Expertise in information and referral activities.
3498     (d)  Knowledge of long-term-care resources, including
3499resources designed to provide services in the least restrictive
3501     (e)  Financial solvency and stability.
3502     (f)  Ability to collect, monitor, and analyze data in a
3503timely and accurate manner, along with systems that meet the
3504department's standards.
3505     (g)  Commitment to adequate staffing by qualified personnel
3506to effectively perform all functions.
3507     (h)  Ability to meet all performance standards established
3508by the department.
3509     (5)(7)  The aging resource center shall have a governing
3510body which shall be the same entity described in s. 20.41(7),
3511and an executive director who may be the same person as
3512described in s. 20.41(7). The governing body shall annually
3513evaluate the performance of the executive director.
3514     (6)(8)  The aging resource center may not be a provider of
3515direct services other than choice counseling as eligible plans
3516become available in each of the regions defined in s.
3517409.981(2), information and referral services, and screening.
3518     (7)(9)  The aging resource center must agree to allow the
3519department to review any financial information the department
3520determines is necessary for monitoring or reporting purposes,
3521including financial relationships.
3522     (8)(10)  The duties and responsibilities of the community
3523care for the elderly lead agencies within each area served by an
3524aging resource center shall be to:
3525     (a)  Develop strong community partnerships to maximize the
3526use of community resources for the purpose of assisting elders
3527to remain in their community settings for as long as it is
3528safely possible.
3529     (b)  Conduct comprehensive assessments of clients that have
3530been determined eligible and develop a care plan consistent with
3531established protocols that ensures that the unique needs of each
3532client are met.
3533     (9)(11)  The services to be administered through the aging
3534resource center shall include those funded by the following
3536     (a)  Community care for the elderly.
3537     (b)  Home care for the elderly.
3538     (c)  Contracted services.
3539     (d)  Alzheimer's disease initiative.
3540     (e)  Aged and disabled adult Medicaid waiver. This
3541paragraph expires October 1, 2013.
3542     (f)  Assisted living for the frail elderly Medicaid waiver.
3543This paragraph expires October 1, 2013.
3544     (g)  Older Americans Act.
3545     (10)(12)  The department shall, prior to designation of an
3546aging resource center, develop by rule operational and quality
3547assurance standards and outcome measures to ensure that clients
3548receiving services through all long-term-care programs
3549administered through an aging resource center are receiving the
3550appropriate care they require and that contractors and
3551subcontractors are adhering to the terms of their contracts and
3552are acting in the best interests of the clients they are
3553serving, consistent with the intent of the Legislature to reduce
3554the use of and cost of nursing home care. The department shall
3555by rule provide operating procedures for aging resource centers,
3556which shall include:
3557     (a)  Minimum standards for financial operation, including
3558audit procedures.
3559     (b)  Procedures for monitoring and sanctioning of service
3561     (c)  Minimum standards for technology utilized by the aging
3562resource center.
3563     (d)  Minimum staff requirements which shall ensure that the
3564aging resource center employs sufficient quality and quantity of
3565staff to adequately meet the needs of the elders residing within
3566the area served by the aging resource center.
3567     (e)  Minimum accessibility standards, including hours of
3569     (f)  Minimum oversight standards for the governing body of
3570the aging resource center to ensure its continuous involvement
3571in, and accountability for, all matters related to the
3572development, implementation, staffing, administration, and
3573operations of the aging resource center.
3574     (g)  Minimum education and experience requirements for
3575executive directors and other executive staff positions of aging
3576resource centers.
3577     (h)  Minimum requirements regarding any executive staff
3578positions that the aging resource center must employ and minimum
3579requirements that a candidate must meet in order to be eligible
3580for appointment to such positions.
3581     (11)(13)  In an area in which the department has designated
3582an area agency on aging as an aging resource center, the
3583department and the agency shall not make payments for the
3584services listed in subsection (9) (11) and the Long-Term Care
3585Community Diversion Project for such persons who were not
3586screened and enrolled through the aging resource center. The
3587department shall cease making payments for recipients in
3588eligible plans as eligible plans become available in each of the
3589regions defined in s. 409.981(2).
3590     (12)(14)  Each aging resource center shall enter into a
3591memorandum of understanding with the department for
3592collaboration with the CARES unit staff. The memorandum of
3593understanding shall outline the staff person responsible for
3594each function and shall provide the staffing levels necessary to
3595carry out the functions of the aging resource center.
3596     (13)(15)  Each aging resource center shall enter into a
3597memorandum of understanding with the Department of Children and
3598Family Services for collaboration with the Economic Self-
3599Sufficiency Unit staff. The memorandum of understanding shall
3600outline which staff persons are responsible for which functions
3601and shall provide the staffing levels necessary to carry out the
3602functions of the aging resource center.
3603     (14)  As eligible plans become available in each of the
3604regions defined in s. 409.981(2), if an aging resource center
3605does not contract with the agency to provide Medicaid long-term
3606care managed care choice counseling pursuant to s. 409.984(1),
3607the aging resource center shall enter into a memorandum of
3608understanding with the agency to coordinate staffing and
3609collaborate with the choice counseling vendor. The memorandum of
3610understanding shall identify the staff responsible for each
3611function and shall provide the staffing levels necessary to
3612carry out the functions of the aging resource center.
3613     (15)(16)  If any of the state activities described in this
3614section are outsourced, either in part or in whole, the contract
3615executing the outsourcing shall mandate that the contractor or
3616its subcontractors shall, either physically or virtually,
3617execute the provisions of the memorandum of understanding
3618instead of the state entity whose function the contractor or
3619subcontractor now performs.
3620     (16)(17)  In order to be eligible to begin transitioning to
3621an aging resource center, an area agency on aging board must
3622ensure that the area agency on aging which it oversees meets all
3623of the minimum requirements set by law and in rule.
3624     (18)  The department shall monitor the three initial
3625projects for aging resource centers and report on the progress
3626of those projects to the Governor, the President of the Senate,
3627and the Speaker of the House of Representatives by June 30,
36282005. The report must include an evaluation of the
3629implementation process.
3630     (17)(19)(a)  Once an aging resource center is operational,
3631the department, in consultation with the agency, may develop
3632capitation rates for any of the programs administered through
3633the aging resource center. Capitation rates for programs shall
3634be based on the historical cost experience of the state in
3635providing those same services to the population age 60 or older
3636residing within each area served by an aging resource center.
3637Each capitated rate may vary by geographic area as determined by
3638the department.
3639     (b)  The department and the agency may determine for each
3640area served by an aging resource center whether it is
3641appropriate, consistent with federal and state laws and
3642regulations, to develop and pay separate capitated rates for
3643each program administered through the aging resource center or
3644to develop and pay capitated rates for service packages which
3645include more than one program or service administered through
3646the aging resource center.
3647     (c)  Once capitation rates have been developed and
3648certified as actuarially sound, the department and the agency
3649may pay service providers the capitated rates for services when
3651     (d)  The department, in consultation with the agency, shall
3652annually reevaluate and recertify the capitation rates,
3653adjusting forward to account for inflation, programmatic
3655     (20)  The department, in consultation with the agency,
3656shall submit to the Governor, the President of the Senate, and
3657the Speaker of the House of Representatives, by December 1,
36582006, a report addressing the feasibility of administering the
3659following services through aging resource centers beginning July
36601, 2007:
3661     (a)  Medicaid nursing home services.
3662     (b)  Medicaid transportation services.
3663     (c)  Medicaid hospice care services.
3664     (d)  Medicaid intermediate care services.
3665     (e)  Medicaid prescribed drug services.
3666     (f)  Medicaid assistive care services.
3667     (g)  Any other long-term-care program or Medicaid service.
3668     (18)(21)  This section shall not be construed to allow an
3669aging resource center to restrict, manage, or impede the local
3670fundraising activities of service providers.
3671     Section 20.  Effective October 1, 2013, sections 430.701,
3672430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3673430.708, and 430.709, Florida Statutes, are repealed.
3674     Section 21.  Sections 409.9301, 409.942, 409.944, 409.945,
3675409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3676as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3677402.87, Florida Statutes, respectively.
3678     Section 22.  Paragraph (a) of subsection (1) of section
3679443.111, Florida Statutes, is amended to read:
3680     443.111  Payment of benefits.-
3681     (1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3682in accordance with rules adopted by the Agency for Workforce
3683Innovation, subject to the following requirements:
3684     (a)  Benefits are payable by mail or electronically.
3685Notwithstanding s. 402.84(4) s. 409.942(4), the agency may
3686develop a system for the payment of benefits by electronic funds
3687transfer, including, but not limited to, debit cards, electronic
3688payment cards, or any other means of electronic payment that the
3689agency deems to be commercially viable or cost-effective.
3690Commodities or services related to the development of such a
3691system shall be procured by competitive solicitation, unless
3692they are purchased from a state term contract pursuant to s.
3693287.056. The agency shall adopt rules necessary to administer
3694the system.
3695     Section 23.  Subsection (4) of section 641.386, Florida
3696Statutes, is amended to read:
3697     641.386  Agent licensing and appointment required;
3699     (4)  All agents and health maintenance organizations shall
3700comply with and be subject to the applicable provisions of ss.
3701641.309 and 409.912(20)(21), and all companies and entities
3702appointing agents shall comply with s. 626.451, when marketing
3703for any health maintenance organization licensed pursuant to
3704this part, including those organizations under contract with the
3705Agency for Health Care Administration to provide health care
3706services to Medicaid recipients or any private entity providing
3707health care services to Medicaid recipients pursuant to a
3708prepaid health plan contract with the Agency for Health Care
3710     Section 24.  Subsections (6) and (7) of section 766.118,
3711Florida Statutes, are renumbered as subsections (7) and (8),
3712respectively, and a new subsection (6) is added to that section,
3713to read:
3714     766.118  Determination of noneconomic damages.-
3717RECIPIENTS.-Notwithstanding subsections (2), (3), (4), and (5),
3718with respect to a cause of action for personal injury or
3719wrongful death arising from medical negligence of practitioners
3720providing services and care to Medicaid recipients as defined in
3721s. 409.901, regardless of the number of such practitioner
3722defendants providing services and care to Medicaid recipients as
3723defined in s. 409.901, noneconomic damages may not exceed
3724$300,000 per claimant. A practitioner providing services and
3725care to Medicaid recipients as defined in s. 409.901 is not
3726liable for more than $200,000 in noneconomic damages, regardless
3727of the number of claimants.
3728     Section 25.  The Agency for Health Care Administration
3729shall develop a plan for implementing s. 409.975(8), Florida
3730Statutes, and shall immediately seek federal approval to
3731implement that subsection. The plan shall include a preliminary
3732calculation of actuarially sound rates and estimated fiscal
3734     Section 26.  Except as otherwise expressly provided in this
3735act, this act shall take effect July 1, 2011, if HB 7107 or
3736similar legislation is adopted in the same legislative session
3737or an extension thereof and becomes law.

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