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 later. The agency shall annually conduct cost
1125reconciliations to determine the amount of cost savings achieved
1126by fee-for-service provider service networks for the dates of
1127service in the period being reconciled. Only payments for
1128covered services for dates of service within the reconciliation
1129period and paid within 6 months after the last date of service
1130in the reconciliation period shall be included. The agency shall
1131perform the necessary adjustments for the inclusion of claims
1132incurred but not reported within the reconciliation for claims
1133that could be received and paid by the agency after the 6-month
1134claims processing time lag. The agency shall provide the results
1135of the reconciliations to the fee-for-service provider service
1136networks within 45 days after the end of the reconciliation
1137period. The fee-for-service provider service networks shall
1138review and provide written comments or a letter of concurrence
1139to the agency within 45 days after receipt of the reconciliation
1140results. This reconciliation shall be considered final.
1141     2.  A provider service network which is reimbursed by the
1142agency on a prepaid basis shall be exempt from parts I and III
1143of chapter 641, but must comply with the solvency requirements
1144in s. 641.2261(2) and meet appropriate financial reserve,
1145quality assurance, and patient rights requirements as
1146established by the agency.
1147     3.  Medicaid recipients assigned to a provider service
1148network shall be chosen equally from those who would otherwise
1149have been assigned to prepaid plans and MediPass. The agency is
1150authorized to seek federal Medicaid waivers as necessary to
1151implement the provisions of this section. This subparagraph
1152expires October 1, 2014. Any contract previously awarded to a
1153provider service network operated by a hospital pursuant to this
1154subsection shall remain in effect for a period of 3 years
1155following the current contract expiration date, regardless of
1156any contractual provisions to the contrary.
1157     4.  A provider service network is a network established or
1158organized and operated by a health care provider, or group of
1159affiliated health care providers, including minority physician
1160networks and emergency room diversion programs that meet the
1161requirements of s. 409.91211, which provides a substantial
1162proportion of the health care items and services under a
1163contract directly through the provider or affiliated group of
1164providers and may make arrangements with physicians or other
1165health care professionals, health care institutions, or any
1166combination of such individuals or institutions to assume all or
1167part of the financial risk on a prospective basis for the
1168provision of basic health services by the physicians, by other
1169health professionals, or through the institutions. The health
1170care providers must have a controlling interest in the governing
1171body of the provider service network organization.
1172     (e)  An entity that provides only comprehensive behavioral
1173health care services to certain Medicaid recipients through an
1174administrative services organization agreement. Such an entity
1175must possess the clinical systems and operational competence to
1176provide comprehensive health care to Medicaid recipients. As
1177used in this paragraph, the term "comprehensive behavioral
1178health care services" means covered mental health and substance
1179abuse treatment services that are available to Medicaid
1180recipients. Any contract awarded under this paragraph must be
1181competitively procured. The agency must ensure that Medicaid
1182recipients have available the choice of at least two managed
1183care plans for their behavioral health care services. This
1184paragraph expires October 1, 2014.
1185     (f)  An entity that provides in-home physician services to
1186test the cost-effectiveness of enhanced home-based medical care
1187to Medicaid recipients with degenerative neurological diseases
1188and other diseases or disabling conditions associated with high
1189costs to Medicaid. The program shall be designed to serve very
1190disabled persons and to reduce Medicaid reimbursed costs for
1191inpatient, outpatient, and emergency department services. The
1192agency shall contract with vendors on a risk-sharing basis.
1193     (g)  Children's provider networks that provide care
1194coordination and care management for Medicaid-eligible pediatric
1195patients, primary care, authorization of specialty care, and
1196other urgent and emergency care through organized providers
1197designed to service Medicaid eligibles under age 18 and
1198pediatric emergency departments' diversion programs. The
1199networks shall provide after-hour operations, including evening
1200and weekend hours, to promote, when appropriate, the use of the
1201children's networks rather than hospital emergency departments.
1202     (f)(h)  An entity authorized in s. 430.205 to contract with
1203the agency and the Department of Elderly Affairs to provide
1204health care and social services on a prepaid or fixed-sum basis
1205to elderly recipients. Such prepaid health care services
1206entities are exempt from the provisions of part I of chapter 641
1207for the first 3 years of operation. An entity recognized under
1208this paragraph that demonstrates to the satisfaction of the
1209Office of Insurance Regulation that it is backed by the full
1210faith and credit of one or more counties in which it operates
1211may be exempted from s. 641.225. This paragraph expires October
12121, 2013.
1213     (g)(i)  A Children's Medical Services Network, as defined
1214in s. 391.021. This paragraph expires October 1, 2014.
1215     (5)  The Agency for Health Care Administration, in
1216partnership with the Department of Elderly Affairs, shall create
1217an integrated, fixed-payment delivery program for Medicaid
1218recipients who are 60 years of age or older or dually eligible
1219for Medicare and Medicaid. The Agency for Health Care
1220Administration shall implement the integrated program initially
1221on a pilot basis in two areas of the state. The pilot areas
1222shall be Area 7 and Area 11 of the Agency for Health Care
1223Administration. Enrollment in the pilot areas shall be on a
1224voluntary basis and in accordance with approved federal waivers
1225and this section. The agency and its program contractors and
1226providers shall not enroll any individual in the integrated
1227program because the individual or the person legally responsible
1228for the individual fails to choose to enroll in the integrated
1229program. Enrollment in the integrated program shall be
1230exclusively by affirmative choice of the eligible individual or
1231by the person legally responsible for the individual. The
1232integrated program must transfer all Medicaid services for
1233eligible elderly individuals who choose to participate into an
1234integrated-care management model designed to serve Medicaid
1235recipients in the community. The integrated program must combine
1236all funding for Medicaid services provided to individuals who
1237are 60 years of age or older or dually eligible for Medicare and
1238Medicaid into the integrated program, including funds for
1239Medicaid home and community-based waiver services; all Medicaid
1240services authorized in ss. 409.905 and 409.906, excluding funds
1241for Medicaid nursing home services unless the agency is able to
1242demonstrate how the integration of the funds will improve
1243coordinated care for these services in a less costly manner; and
1244Medicare coinsurance and deductibles for persons dually eligible
1245for Medicaid and Medicare as prescribed in s. 409.908(13).
1246     (a)  Individuals who are 60 years of age or older or dually
1247eligible for Medicare and Medicaid and enrolled in the
1248developmental disabilities waiver program, the family and
1249supported-living waiver program, the project AIDS care waiver
1250program, the traumatic brain injury and spinal cord injury
1251waiver program, the consumer-directed care waiver program, and
1252the program of all-inclusive care for the elderly program, and
1253residents of institutional care facilities for the
1254developmentally disabled, must be excluded from the integrated
1256     (b)  Managed care entities who meet or exceed the agency's
1257minimum standards are eligible to operate the integrated
1258program. Entities eligible to participate include managed care
1259organizations licensed under chapter 641, including entities
1260eligible to participate in the nursing home diversion program,
1261other qualified providers as defined in s. 430.703(7), community
1262care for the elderly lead agencies, and other state-certified
1263community service networks that meet comparable standards as
1264defined by the agency, in consultation with the Department of
1265Elderly Affairs and the Office of Insurance Regulation, to be
1266financially solvent and able to take on financial risk for
1267managed care. Community service networks that are certified
1268pursuant to the comparable standards defined by the agency are
1269not required to be licensed under chapter 641. Managed care
1270entities who operate the integrated program shall be subject to
1271s. 408.7056. Eligible entities shall choose to serve enrollees
1272who are dually eligible for Medicare and Medicaid, enrollees who
1273are 60 years of age or older, or both.
1274     (c)  The agency must ensure that the capitation-rate-
1275setting methodology for the integrated program is actuarially
1276sound and reflects the intent to provide quality care in the
1277least restrictive setting. The agency must also require
1278integrated-program providers to develop a credentialing system
1279for service providers and to contract with all Gold Seal nursing
1280homes, where feasible, and exclude, where feasible, chronically
1281poor-performing facilities and providers as defined by the
1282agency. The integrated program must develop and maintain an
1283informal provider grievance system that addresses provider
1284payment and contract problems. The agency shall also establish a
1285formal grievance system to address those issues that were not
1286resolved through the informal grievance system. The integrated
1287program must provide that if the recipient resides in a
1288noncontracted residential facility licensed under chapter 400 or
1289chapter 429 at the time of enrollment in the integrated program,
1290the recipient must be permitted to continue to reside in the
1291noncontracted facility as long as the recipient desires. The
1292integrated program must also provide that, in the absence of a
1293contract between the integrated-program provider and the
1294residential facility licensed under chapter 400 or chapter 429,
1295current Medicaid rates must prevail. The integrated-program
1296provider must ensure that electronic nursing home claims that
1297contain sufficient information for processing are paid within 10
1298business days after receipt. Alternately, the integrated-program
1299provider may establish a capitated payment mechanism to
1300prospectively pay nursing homes at the beginning of each month.
1301The agency and the Department of Elderly Affairs must jointly
1302develop procedures to manage the services provided through the
1303integrated program in order to ensure quality and recipient
1305     (d)  The Office of Program Policy Analysis and Government
1306Accountability, in consultation with the Auditor General, shall
1307comprehensively evaluate the pilot project for the integrated,
1308fixed-payment delivery program for Medicaid recipients created
1309under this subsection. The evaluation shall begin as soon as
1310Medicaid recipients are enrolled in the managed care pilot
1311program plans and shall continue for 24 months thereafter. The
1312evaluation must include assessments of each managed care plan in
1313the integrated program with regard to cost savings; consumer
1314education, choice, and access to services; coordination of care;
1315and quality of care. The evaluation must describe administrative
1316or legal barriers to the implementation and operation of the
1317pilot program and include recommendations regarding statewide
1318expansion of the pilot program. The office shall submit its
1319evaluation report to the Governor, the President of the Senate,
1320and the Speaker of the House of Representatives no later than
1321December 31, 2009.
1322     (e)  The agency may seek federal waivers or Medicaid state
1323plan amendments and adopt rules as necessary to administer the
1324integrated program. The agency may implement the approved
1325federal waivers and other provisions as specified in this
1327     (f)  The implementation of the integrated, fixed-payment
1328delivery program created under this subsection is subject to an
1329appropriation in the General Appropriations Act.
1330     (5)(6)  The agency may contract with any public or private
1331entity otherwise authorized by this section on a prepaid or
1332fixed-sum basis for the provision of health care services to
1333recipients. An entity may provide prepaid services to
1334recipients, either directly or through arrangements with other
1335entities, if each entity involved in providing services:
1336     (a)  Is organized primarily for the purpose of providing
1337health care or other services of the type regularly offered to
1338Medicaid recipients;
1339     (b)  Ensures that services meet the standards set by the
1340agency for quality, appropriateness, and timeliness;
1341     (c)  Makes provisions satisfactory to the agency for
1342insolvency protection and ensures that neither enrolled Medicaid
1343recipients nor the agency will be liable for the debts of the
1345     (d)  Submits to the agency, if a private entity, a
1346financial plan that the agency finds to be fiscally sound and
1347that provides for working capital in the form of cash or
1348equivalent liquid assets excluding revenues from Medicaid
1349premium payments equal to at least the first 3 months of
1350operating expenses or $200,000, whichever is greater;
1351     (e)  Furnishes evidence satisfactory to the agency of
1352adequate liability insurance coverage or an adequate plan of
1353self-insurance to respond to claims for injuries arising out of
1354the furnishing of health care;
1355     (f)  Provides, through contract or otherwise, for periodic
1356review of its medical facilities and services, as required by
1357the agency; and
1358     (g)  Provides organizational, operational, financial, and
1359other information required by the agency.
1361This subsection expires October 1, 2014.
1362     (6)(7)  The agency may contract on a prepaid or fixed-sum
1363basis with any health insurer that:
1364     (a)  Pays for health care services provided to enrolled
1365Medicaid recipients in exchange for a premium payment paid by
1366the agency;
1367     (b)  Assumes the underwriting risk; and
1368     (c)  Is organized and licensed under applicable provisions
1369of the Florida Insurance Code and is currently in good standing
1370with the Office of Insurance Regulation.
1372This subsection expires October 1, 2014.
1373     (7)(8)(a)  The agency may contract on a prepaid or fixed-
1374sum basis with an exclusive provider organization to provide
1375health care services to Medicaid recipients provided that the
1376exclusive provider organization meets applicable managed care
1377plan requirements in this section, ss. 409.9122, 409.9123,
1378409.9128, and 627.6472, and other applicable provisions of law.
1379This subsection expires October 1, 2014.
1380     (b)  For a period of no longer than 24 months after the
1381effective date of this paragraph, when a member of an exclusive
1382provider organization that is contracted by the agency to
1383provide health care services to Medicaid recipients in rural
1384areas without a health maintenance organization obtains services
1385from a provider that participates in the Medicaid program in
1386this state, the provider shall be paid in accordance with the
1387appropriate fee schedule for services provided to eligible
1388Medicaid recipients. The agency may seek waiver authority to
1389implement this paragraph.
1390     (8)(9)  The Agency for Health Care Administration may
1391provide cost-effective purchasing of chiropractic services on a
1392fee-for-service basis to Medicaid recipients through
1393arrangements with a statewide chiropractic preferred provider
1394organization incorporated in this state as a not-for-profit
1395corporation. The agency shall ensure that the benefit limits and
1396prior authorization requirements in the current Medicaid program
1397shall apply to the services provided by the chiropractic
1398preferred provider organization. This subsection expires October
13991, 2014.
1400     (9)(10)  The agency shall not contract on a prepaid or
1401fixed-sum basis for Medicaid services with an entity which knows
1402or reasonably should know that any officer, director, agent,
1403managing employee, or owner of stock or beneficial interest in
1404excess of 5 percent common or preferred stock, or the entity
1405itself, has been found guilty of, regardless of adjudication, or
1406entered a plea of nolo contendere, or guilty, to:
1407     (a)  Fraud;
1408     (b)  Violation of federal or state antitrust statutes,
1409including those proscribing price fixing between competitors and
1410the allocation of customers among competitors;
1411     (c)  Commission of a felony involving embezzlement, theft,
1412forgery, income tax evasion, bribery, falsification or
1413destruction of records, making false statements, receiving
1414stolen property, making false claims, or obstruction of justice;
1416     (d)  Any crime in any jurisdiction which directly relates
1417to the provision of health services on a prepaid or fixed-sum
1420This subsection expires October 1, 2014.
1421     (10)(11)  The agency, after notifying the Legislature, may
1422apply for waivers of applicable federal laws and regulations as
1423necessary to implement more appropriate systems of health care
1424for Medicaid recipients and reduce the cost of the Medicaid
1425program to the state and federal governments and shall implement
1426such programs, after legislative approval, within a reasonable
1427period of time after federal approval. These programs must be
1428designed primarily to reduce the need for inpatient care,
1429custodial care and other long-term or institutional care, and
1430other high-cost services. Prior to seeking legislative approval
1431of such a waiver as authorized by this subsection, the agency
1432shall provide notice and an opportunity for public comment.
1433Notice shall be provided to all persons who have made requests
1434of the agency for advance notice and shall be published in the
1435Florida Administrative Weekly not less than 28 days prior to the
1436intended action. This subsection expires October 1, 2016.
1437     (11)(12)  The agency shall establish a postpayment
1438utilization control program designed to identify recipients who
1439may inappropriately overuse or underuse Medicaid services and
1440shall provide methods to correct such misuse. This subsection
1441expires October 1, 2014.
1442     (12)(13)  The agency shall develop and provide coordinated
1443systems of care for Medicaid recipients and may contract with
1444public or private entities to develop and administer such
1445systems of care among public and private health care providers
1446in a given geographic area. This subsection expires October 1,
1448     (13)(14)(a)  The agency shall operate or contract for the
1449operation of utilization management and incentive systems
1450designed to encourage cost-effective use of services and to
1451eliminate services that are medically unnecessary. The agency
1452shall track Medicaid provider prescription and billing patterns
1453and evaluate them against Medicaid medical necessity criteria
1454and coverage and limitation guidelines adopted by rule. Medical
1455necessity determination requires that service be consistent with
1456symptoms or confirmed diagnosis of illness or injury under
1457treatment and not in excess of the patient's needs. The agency
1458shall conduct reviews of provider exceptions to peer group norms
1459and shall, using statistical methodologies, provider profiling,
1460and analysis of billing patterns, detect and investigate
1461abnormal or unusual increases in billing or payment of claims
1462for Medicaid services and medically unnecessary provision of
1463services. Providers that demonstrate a pattern of submitting
1464claims for medically unnecessary services shall be referred to
1465the Medicaid program integrity unit for investigation. In its
1466annual report, required in s. 409.913, the agency shall report
1467on its efforts to control overutilization as described in this
1468subsection paragraph. This subsection expires October 1, 2014.
1469     (b)  The agency shall develop a procedure for determining
1470whether health care providers and service vendors can provide
1471the Medicaid program using a business case that demonstrates
1472whether a particular good or service can offset the cost of
1473providing the good or service in an alternative setting or
1474through other means and therefore should receive a higher
1475reimbursement. The business case must include, but need not be
1476limited to:
1477     1.  A detailed description of the good or service to be
1478provided, a description and analysis of the agency's current
1479performance of the service, and a rationale documenting how
1480providing the service in an alternative setting would be in the
1481best interest of the state, the agency, and its clients.
1482     2.  A cost-benefit analysis documenting the estimated
1483specific direct and indirect costs, savings, performance
1484improvements, risks, and qualitative and quantitative benefits
1485involved in or resulting from providing the service. The cost-
1486benefit analysis must include a detailed plan and timeline
1487identifying all actions that must be implemented to realize
1488expected benefits. The Secretary of Health Care Administration
1489shall verify that all costs, savings, and benefits are valid and
1491     (c)  If the agency determines that the increased
1492reimbursement is cost-effective, the agency shall recommend a
1493change in the reimbursement schedule for that particular good or
1494service. If, within 12 months after implementing any rate change
1495under this procedure, the agency determines that costs were not
1496offset by the increased reimbursement schedule, the agency may
1497revert to the former reimbursement schedule for the particular
1498good or service.
1499     (14)(15)(a)  The agency shall operate the Comprehensive
1500Assessment and Review for Long-Term Care Services (CARES)
1501nursing facility preadmission screening program to ensure that
1502Medicaid payment for nursing facility care is made only for
1503individuals whose conditions require such care and to ensure
1504that long-term care services are provided in the setting most
1505appropriate to the needs of the person and in the most
1506economical manner possible. The CARES program shall also ensure
1507that individuals participating in Medicaid home and community-
1508based waiver programs meet criteria for those programs,
1509consistent with approved federal waivers.
1510     (b)  The agency shall operate the CARES program through an
1511interagency agreement with the Department of Elderly Affairs.
1512The agency, in consultation with the Department of Elderly
1513Affairs, may contract for any function or activity of the CARES
1514program, including any function or activity required by 42
1515C.F.R. part 483.20, relating to preadmission screening and
1516resident review.
1517     (c)  Prior to making payment for nursing facility services
1518for a Medicaid recipient, the agency must verify that the
1519nursing facility preadmission screening program has determined
1520that the individual requires nursing facility care and that the
1521individual cannot be safely served in community-based programs.
1522The nursing facility preadmission screening program shall refer
1523a Medicaid recipient to a community-based program if the
1524individual could be safely served at a lower cost and the
1525recipient chooses to participate in such program. For
1526individuals whose nursing home stay is initially funded by
1527Medicare and Medicare coverage is being terminated for lack of
1528progress towards rehabilitation, CARES staff shall consult with
1529the person making the determination of progress toward
1530rehabilitation to ensure that the recipient is not being
1531inappropriately disqualified from Medicare coverage. If, in
1532their professional judgment, CARES staff believes that a
1533Medicare beneficiary is still making progress toward
1534rehabilitation, they may assist the Medicare beneficiary with an
1535appeal of the disqualification from Medicare coverage. The use
1536of CARES teams to review Medicare denials for coverage under
1537this section is authorized only if it is determined that such
1538reviews qualify for federal matching funds through Medicaid. The
1539agency shall seek or amend federal waivers as necessary to
1540implement this section.
1541     (d)  For the purpose of initiating immediate prescreening
1542and diversion assistance for individuals residing in nursing
1543homes and in order to make families aware of alternative long-
1544term care resources so that they may choose a more cost-
1545effective setting for long-term placement, CARES staff shall
1546conduct an assessment and review of a sample of individuals
1547whose nursing home stay is expected to exceed 20 days,
1548regardless of the initial funding source for the nursing home
1549placement. CARES staff shall provide counseling and referral
1550services to these individuals regarding choosing appropriate
1551long-term care alternatives. This paragraph does not apply to
1552continuing care facilities licensed under chapter 651 or to
1553retirement communities that provide a combination of nursing
1554home, independent living, and other long-term care services.
1555     (e)  By January 15 of each year, the agency shall submit a
1556report to the Legislature describing the operations of the CARES
1557program. The report must describe:
1558     1.  Rate of diversion to community alternative programs;
1559     2.  CARES program staffing needs to achieve additional
1561     3.  Reasons the program is unable to place individuals in
1562less restrictive settings when such individuals desired such
1563services and could have been served in such settings;
1564     4.  Barriers to appropriate placement, including barriers
1565due to policies or operations of other agencies or state-funded
1566programs; and
1567     5.  Statutory changes necessary to ensure that individuals
1568in need of long-term care services receive care in the least
1569restrictive environment.
1570     (f)  The Department of Elderly Affairs shall track
1571individuals over time who are assessed under the CARES program
1572and who are diverted from nursing home placement. By January 15
1573of each year, the department shall submit to the Legislature a
1574longitudinal study of the individuals who are diverted from
1575nursing home placement. The study must include:
1576     1.  The demographic characteristics of the individuals
1577assessed and diverted from nursing home placement, including,
1578but not limited to, age, race, gender, frailty, caregiver
1579status, living arrangements, and geographic location;
1580     2.  A summary of community services provided to individuals
1581for 1 year after assessment and diversion;
1582     3.  A summary of inpatient hospital admissions for
1583individuals who have been diverted; and
1584     4.  A summary of the length of time between diversion and
1585subsequent entry into a nursing home or death.
1587This subsection expires October 1, 2013.
1588     (15)(16)(a)  The agency shall identify health care
1589utilization and price patterns within the Medicaid program which
1590are not cost-effective or medically appropriate and assess the
1591effectiveness of new or alternate methods of providing and
1592monitoring service, and may implement such methods as it
1593considers appropriate. Such methods may include disease
1594management initiatives, an integrated and systematic approach
1595for managing the health care needs of recipients who are at risk
1596of or diagnosed with a specific disease by using best practices,
1597prevention strategies, clinical-practice improvement, clinical
1598interventions and protocols, outcomes research, information
1599technology, and other tools and resources to reduce overall
1600costs and improve measurable outcomes.
1601     (b)  The responsibility of the agency under this subsection
1602shall include the development of capabilities to identify actual
1603and optimal practice patterns; patient and provider educational
1604initiatives; methods for determining patient compliance with
1605prescribed treatments; fraud, waste, and abuse prevention and
1606detection programs; and beneficiary case management programs.
1607     1.  The practice pattern identification program shall
1608evaluate practitioner prescribing patterns based on national and
1609regional practice guidelines, comparing practitioners to their
1610peer groups. The agency and its Drug Utilization Review Board
1611shall consult with the Department of Health and a panel of
1612practicing health care professionals consisting of the
1613following: the Speaker of the House of Representatives and the
1614President of the Senate shall each appoint three physicians
1615licensed under chapter 458 or chapter 459; and the Governor
1616shall appoint two pharmacists licensed under chapter 465 and one
1617dentist licensed under chapter 466 who is an oral surgeon. Terms
1618of the panel members shall expire at the discretion of the
1619appointing official. The advisory panel shall be responsible for
1620evaluating treatment guidelines and recommending ways to
1621incorporate their use in the practice pattern identification
1622program. Practitioners who are prescribing inappropriately or
1623inefficiently, as determined by the agency, may have their
1624prescribing of certain drugs subject to prior authorization or
1625may be terminated from all participation in the Medicaid
1627     2.  The agency shall also develop educational interventions
1628designed to promote the proper use of medications by providers
1629and beneficiaries.
1630     3.  The agency shall implement a pharmacy fraud, waste, and
1631abuse initiative that may include a surety bond or letter of
1632credit requirement for participating pharmacies, enhanced
1633provider auditing practices, the use of additional fraud and
1634abuse software, recipient management programs for beneficiaries
1635inappropriately using their benefits, and other steps that will
1636eliminate provider and recipient fraud, waste, and abuse. The
1637initiative shall address enforcement efforts to reduce the
1638number and use of counterfeit prescriptions.
1639     4.  By September 30, 2002, the agency shall contract with
1640an entity in the state to implement a wireless handheld clinical
1641pharmacology drug information database for practitioners. The
1642initiative shall be designed to enhance the agency's efforts to
1643reduce fraud, abuse, and errors in the prescription drug benefit
1644program and to otherwise further the intent of this paragraph.
1645     5.  By April 1, 2006, the agency shall contract with an
1646entity to design a database of clinical utilization information
1647or electronic medical records for Medicaid providers. This
1648system must be web-based and allow providers to review on a
1649real-time basis the utilization of Medicaid services, including,
1650but not limited to, physician office visits, inpatient and
1651outpatient hospitalizations, laboratory and pathology services,
1652radiological and other imaging services, dental care, and
1653patterns of dispensing prescription drugs in order to coordinate
1654care and identify potential fraud and abuse.
1655     6.  The agency may apply for any federal waivers needed to
1656administer this paragraph.
1658This subsection expires October 1, 2014.
1659     (16)(17)  An entity contracting on a prepaid or fixed-sum
1660basis shall meet the surplus requirements of s. 641.225. If an
1661entity's surplus falls below an amount equal to the surplus
1662requirements of s. 641.225, the agency shall prohibit the entity
1663from engaging in marketing and preenrollment activities, shall
1664cease to process new enrollments, and may not renew the entity's
1665contract until the required balance is achieved. The
1666requirements of this subsection do not apply:
1667     (a)  Where a public entity agrees to fund any deficit
1668incurred by the contracting entity; or
1669     (b)  Where the entity's performance and obligations are
1670guaranteed in writing by a guaranteeing organization which:
1671     1.  Has been in operation for at least 5 years and has
1672assets in excess of $50 million; or
1673     2.  Submits a written guarantee acceptable to the agency
1674which is irrevocable during the term of the contracting entity's
1675contract with the agency and, upon termination of the contract,
1676until the agency receives proof of satisfaction of all
1677outstanding obligations incurred under the contract.
1679This subsection expires October 1, 2014.
1680     (17)(18)(a)  The agency may require an entity contracting
1681on a prepaid or fixed-sum basis to establish a restricted
1682insolvency protection account with a federally guaranteed
1683financial institution licensed to do business in this state. The
1684entity shall deposit into that account 5 percent of the
1685capitation payments made by the agency each month until a
1686maximum total of 2 percent of the total current contract amount
1687is reached. The restricted insolvency protection account may be
1688drawn upon with the authorized signatures of two persons
1689designated by the entity and two representatives of the agency.
1690If the agency finds that the entity is insolvent, the agency may
1691draw upon the account solely with the two authorized signatures
1692of representatives of the agency, and the funds may be disbursed
1693to meet financial obligations incurred by the entity under the
1694prepaid contract. If the contract is terminated, expired, or not
1695continued, the account balance must be released by the agency to
1696the entity upon receipt of proof of satisfaction of all
1697outstanding obligations incurred under this contract.
1698     (b)  The agency may waive the insolvency protection account
1699requirement in writing when evidence is on file with the agency
1700of adequate insolvency insurance and reinsurance that will
1701protect enrollees if the entity becomes unable to meet its
1704     (18)(19)  An entity that contracts with the agency on a
1705prepaid or fixed-sum basis for the provision of Medicaid
1706services shall reimburse any hospital or physician that is
1707outside the entity's authorized geographic service area as
1708specified in its contract with the agency, and that provides
1709services authorized by the entity to its members, at a rate
1710negotiated with the hospital or physician for the provision of
1711services or according to the lesser of the following:
1712     (a)  The usual and customary charges made to the general
1713public by the hospital or physician; or
1714     (b)  The Florida Medicaid reimbursement rate established
1715for the hospital or physician.
1717This subsection expires October 1, 2014.
1718     (19)(20)  When a merger or acquisition of a Medicaid
1719prepaid contractor has been approved by the Office of Insurance
1720Regulation pursuant to s. 628.4615, the agency shall approve the
1721assignment or transfer of the appropriate Medicaid prepaid
1722contract upon request of the surviving entity of the merger or
1723acquisition if the contractor and the other entity have been in
1724good standing with the agency for the most recent 12-month
1725period, unless the agency determines that the assignment or
1726transfer would be detrimental to the Medicaid recipients or the
1727Medicaid program. To be in good standing, an entity must not
1728have failed accreditation or committed any material violation of
1729the requirements of s. 641.52 and must meet the Medicaid
1730contract requirements. For purposes of this section, a merger or
1731acquisition means a change in controlling interest of an entity,
1732including an asset or stock purchase. This subsection expires
1733October 1, 2014.
1734     (20)(21)  Any entity contracting with the agency pursuant
1735to this section to provide health care services to Medicaid
1736recipients is prohibited from engaging in any of the following
1737practices or activities:
1738     (a)  Practices that are discriminatory, including, but not
1739limited to, attempts to discourage participation on the basis of
1740actual or perceived health status.
1741     (b)  Activities that could mislead or confuse recipients,
1742or misrepresent the organization, its marketing representatives,
1743or the agency. Violations of this paragraph include, but are not
1744limited to:
1745     1.  False or misleading claims that marketing
1746representatives are employees or representatives of the state or
1747county, or of anyone other than the entity or the organization
1748by whom they are reimbursed.
1749     2.  False or misleading claims that the entity is
1750recommended or endorsed by any state or county agency, or by any
1751other organization which has not certified its endorsement in
1752writing to the entity.
1753     3.  False or misleading claims that the state or county
1754recommends that a Medicaid recipient enroll with an entity.
1755     4.  Claims that a Medicaid recipient will lose benefits
1756under the Medicaid program, or any other health or welfare
1757benefits to which the recipient is legally entitled, if the
1758recipient does not enroll with the entity.
1759     (c)  Granting or offering of any monetary or other valuable
1760consideration for enrollment, except as authorized by subsection
1761(23) (24).
1762     (d)  Door-to-door solicitation of recipients who have not
1763contacted the entity or who have not invited the entity to make
1764a presentation.
1765     (e)  Solicitation of Medicaid recipients by marketing
1766representatives stationed in state offices unless approved and
1767supervised by the agency or its agent and approved by the
1768affected state agency when solicitation occurs in an office of
1769the state agency. The agency shall ensure that marketing
1770representatives stationed in state offices shall market their
1771managed care plans to Medicaid recipients only in designated
1772areas and in such a way as to not interfere with the recipients'
1773activities in the state office.
1774     (f)  Enrollment of Medicaid recipients.
1776     (21)(22)  The agency may impose a fine for a violation of
1777this section or the contract with the agency by a person or
1778entity that is under contract with the agency. With respect to
1779any nonwillful violation, such fine shall not exceed $2,500 per
1780violation. In no event shall such fine exceed an aggregate
1781amount of $10,000 for all nonwillful violations arising out of
1782the same action. With respect to any knowing and willful
1783violation of this section or the contract with the agency, the
1784agency may impose a fine upon the entity in an amount not to
1785exceed $20,000 for each such violation. In no event shall such
1786fine exceed an aggregate amount of $100,000 for all knowing and
1787willful violations arising out of the same action. This
1788subsection expires October 1, 2014.
1789     (22)(23)  A health maintenance organization or a person or
1790entity exempt from chapter 641 that is under contract with the
1791agency for the provision of health care services to Medicaid
1792recipients may not use or distribute marketing materials used to
1793solicit Medicaid recipients, unless such materials have been
1794approved by the agency. The provisions of this subsection do not
1795apply to general advertising and marketing materials used by a
1796health maintenance organization to solicit both non-Medicaid
1797subscribers and Medicaid recipients. This subsection expires
1798October 1, 2014.
1799     (23)(24)  Upon approval by the agency, health maintenance
1800organizations and persons or entities exempt from chapter 641
1801that are under contract with the agency for the provision of
1802health care services to Medicaid recipients may be permitted
1803within the capitation rate to provide additional health benefits
1804that the agency has found are of high quality, are practicably
1805available, provide reasonable value to the recipient, and are
1806provided at no additional cost to the state. This subsection
1807expires October 1, 2014.
1808     (24)(25)  The agency shall utilize the statewide health
1809maintenance organization complaint hotline for the purpose of
1810investigating and resolving Medicaid and prepaid health plan
1811complaints, maintaining a record of complaints and confirmed
1812problems, and receiving disenrollment requests made by
1813recipients. This subsection expires October 1, 2014.
1814     (25)(26)  The agency shall require the publication of the
1815health maintenance organization's and the prepaid health plan's
1816consumer services telephone numbers and the "800" telephone
1817number of the statewide health maintenance organization
1818complaint hotline on each Medicaid identification card issued by
1819a health maintenance organization or prepaid health plan
1820contracting with the agency to serve Medicaid recipients and on
1821each subscriber handbook issued to a Medicaid recipient. This
1822subsection expires October 1, 2014.
1823     (26)(27)  The agency shall establish a health care quality
1824improvement system for those entities contracting with the
1825agency pursuant to this section, incorporating all the standards
1826and guidelines developed by the Medicaid Bureau of the Health
1827Care Financing Administration as a part of the quality assurance
1828reform initiative. The system shall include, but need not be
1829limited to, the following:
1830     (a)  Guidelines for internal quality assurance programs,
1831including standards for:
1832     1.  Written quality assurance program descriptions.
1833     2.  Responsibilities of the governing body for monitoring,
1834evaluating, and making improvements to care.
1835     3.  An active quality assurance committee.
1836     4.  Quality assurance program supervision.
1837     5.  Requiring the program to have adequate resources to
1838effectively carry out its specified activities.
1839     6.  Provider participation in the quality assurance
1841     7.  Delegation of quality assurance program activities.
1842     8.  Credentialing and recredentialing.
1843     9.  Enrollee rights and responsibilities.
1844     10.  Availability and accessibility to services and care.
1845     11.  Ambulatory care facilities.
1846     12.  Accessibility and availability of medical records, as
1847well as proper recordkeeping and process for record review.
1848     13.  Utilization review.
1849     14.  A continuity of care system.
1850     15.  Quality assurance program documentation.
1851     16.  Coordination of quality assurance activity with other
1852management activity.
1853     17.  Delivering care to pregnant women and infants; to
1854elderly and disabled recipients, especially those who are at
1855risk of institutional placement; to persons with developmental
1856disabilities; and to adults who have chronic, high-cost medical
1858     (b)  Guidelines which require the entities to conduct
1859quality-of-care studies which:
1860     1.  Target specific conditions and specific health service
1861delivery issues for focused monitoring and evaluation.
1862     2.  Use clinical care standards or practice guidelines to
1863objectively evaluate the care the entity delivers or fails to
1864deliver for the targeted clinical conditions and health services
1865delivery issues.
1866     3.  Use quality indicators derived from the clinical care
1867standards or practice guidelines to screen and monitor care and
1868services delivered.
1869     (c)  Guidelines for external quality review of each
1870contractor which require: focused studies of patterns of care;
1871individual care review in specific situations; and followup
1872activities on previous pattern-of-care study findings and
1873individual-care-review findings. In designing the external
1874quality review function and determining how it is to operate as
1875part of the state's overall quality improvement system, the
1876agency shall construct its external quality review organization
1877and entity contracts to address each of the following:
1878     1.  Delineating the role of the external quality review
1880     2.  Length of the external quality review organization
1881contract with the state.
1882     3.  Participation of the contracting entities in designing
1883external quality review organization review activities.
1884     4.  Potential variation in the type of clinical conditions
1885and health services delivery issues to be studied at each plan.
1886     5.  Determining the number of focused pattern-of-care
1887studies to be conducted for each plan.
1888     6.  Methods for implementing focused studies.
1889     7.  Individual care review.
1890     8.  Followup activities.
1892This subsection expires October 1, 2016.
1893     (27)(28)  In order to ensure that children receive health
1894care services for which an entity has already been compensated,
1895an entity contracting with the agency pursuant to this section
1896shall achieve an annual Early and Periodic Screening, Diagnosis,
1897and Treatment (EPSDT) Service screening rate of at least 60
1898percent for those recipients continuously enrolled for at least
18998 months. The agency shall develop a method by which the EPSDT
1900screening rate shall be calculated. For any entity which does
1901not achieve the annual 60 percent rate, the entity must submit a
1902corrective action plan for the agency's approval. If the entity
1903does not meet the standard established in the corrective action
1904plan during the specified timeframe, the agency is authorized to
1905impose appropriate contract sanctions. At least annually, the
1906agency shall publicly release the EPSDT Services screening rates
1907of each entity it has contracted with on a prepaid basis to
1908serve Medicaid recipients. This subsection expires October 1,
1910     (28)(29)  The agency shall perform enrollments and
1911disenrollments for Medicaid recipients who are eligible for
1912MediPass or managed care plans. Notwithstanding the prohibition
1913contained in paragraph (20)(21)(f), managed care plans may
1914perform preenrollments of Medicaid recipients under the
1915supervision of the agency or its agents. For the purposes of
1916this section, the term "preenrollment" means the provision of
1917marketing and educational materials to a Medicaid recipient and
1918assistance in completing the application forms, but does not
1919include actual enrollment into a managed care plan. An
1920application for enrollment may not be deemed complete until the
1921agency or its agent verifies that the recipient made an
1922informed, voluntary choice. The agency, in cooperation with the
1923Department of Children and Family Services, may test new
1924marketing initiatives to inform Medicaid recipients about their
1925managed care options at selected sites. The agency may contract
1926with a third party to perform managed care plan and MediPass
1927enrollment and disenrollment services for Medicaid recipients
1928and may adopt rules to administer such services. The agency may
1929adjust the capitation rate only to cover the costs of a third-
1930party enrollment and disenrollment contract, and for agency
1931supervision and management of the managed care plan enrollment
1932and disenrollment contract. This subsection expires October 1,
1934     (29)(30)  Any lists of providers made available to Medicaid
1935recipients, MediPass enrollees, or managed care plan enrollees
1936shall be arranged alphabetically showing the provider's name and
1937specialty and, separately, by specialty in alphabetical order.
1938This subsection expires October 1, 2014.
1939     (30)(31)  The agency shall establish an enhanced managed
1940care quality assurance oversight function, to include at least
1941the following components:
1942     (a)  At least quarterly analysis and followup, including
1943sanctions as appropriate, of managed care participant
1944utilization of services.
1945     (b)  At least quarterly analysis and followup, including
1946sanctions as appropriate, of quality findings of the Medicaid
1947peer review organization and other external quality assurance
1949     (c)  At least quarterly analysis and followup, including
1950sanctions as appropriate, of the fiscal viability of managed
1951care plans.
1952     (d)  At least quarterly analysis and followup, including
1953sanctions as appropriate, of managed care participant
1954satisfaction and disenrollment surveys.
1955     (e)  The agency shall conduct regular and ongoing Medicaid
1956recipient satisfaction surveys.
1958The analyses and followup activities conducted by the agency
1959under its enhanced managed care quality assurance oversight
1960function shall not duplicate the activities of accreditation
1961reviewers for entities regulated under part III of chapter 641,
1962but may include a review of the finding of such reviewers. This
1963subsection expires October 1, 2014.
1964     (31)(32)  Each managed care plan that is under contract
1965with the agency to provide health care services to Medicaid
1966recipients shall annually conduct a background check with the
1967Department of Law Enforcement of all persons with ownership
1968interest of 5 percent or more or executive management
1969responsibility for the managed care plan and shall submit to the
1970agency information concerning any such person who has been found
1971guilty of, regardless of adjudication, or has entered a plea of
1972nolo contendere or guilty to, any of the offenses listed in s.
1973435.04. This subsection expires October 1, 2014.
1974     (32)(33)  The agency shall, by rule, develop a process
1975whereby a Medicaid managed care plan enrollee who wishes to
1976enter hospice care may be disenrolled from the managed care plan
1977within 24 hours after contacting the agency regarding such
1978request. The agency rule shall include a methodology for the
1979agency to recoup managed care plan payments on a pro rata basis
1980if payment has been made for the enrollment month when
1981disenrollment occurs. This subsection expires October 1, 2014.
1982     (33)(34)  The agency and entities that contract with the
1983agency to provide health care services to Medicaid recipients
1984under this section or ss. 409.91211 and 409.9122 must comply
1985with the provisions of s. 641.513 in providing emergency
1986services and care to Medicaid recipients and MediPass
1987recipients. Where feasible, safe, and cost-effective, the agency
1988shall encourage hospitals, emergency medical services providers,
1989and other public and private health care providers to work
1990together in their local communities to enter into agreements or
1991arrangements to ensure access to alternatives to emergency
1992services and care for those Medicaid recipients who need
1993nonemergent care. The agency shall coordinate with hospitals,
1994emergency medical services providers, private health plans,
1995capitated managed care networks as established in s. 409.91211,
1996and other public and private health care providers to implement
1997the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1998and 641.31097 to develop and implement emergency department
1999diversion programs for Medicaid recipients. This subsection
2000expires October 1, 2014.
2001     (34)(35)  All entities providing health care services to
2002Medicaid recipients shall make available, and encourage all
2003pregnant women and mothers with infants to receive, and provide
2004documentation in the medical records to reflect, the following:
2005     (a)  Healthy Start prenatal or infant screening.
2006     (b)  Healthy Start care coordination, when screening or
2007other factors indicate need.
2008     (c)  Healthy Start enhanced services in accordance with the
2009prenatal or infant screening results.
2010     (d)  Immunizations in accordance with recommendations of
2011the Advisory Committee on Immunization Practices of the United
2012States Public Health Service and the American Academy of
2013Pediatrics, as appropriate.
2014     (e)  Counseling and services for family planning to all
2015women and their partners.
2016     (f)  A scheduled postpartum visit for the purpose of
2017voluntary family planning, to include discussion of all methods
2018of contraception, as appropriate.
2019     (g)  Referral to the Special Supplemental Nutrition Program
2020for Women, Infants, and Children (WIC).
2022This subsection expires October 1, 2014.
2023     (35)(36)  Any entity that provides Medicaid prepaid health
2024plan services shall ensure the appropriate coordination of
2025health care services with an assisted living facility in cases
2026where a Medicaid recipient is both a member of the entity's
2027prepaid health plan and a resident of the assisted living
2028facility. If the entity is at risk for Medicaid targeted case
2029management and behavioral health services, the entity shall
2030inform the assisted living facility of the procedures to follow
2031should an emergent condition arise. This subsection expires
2032October 1, 2014.
2033     (37)  The agency may seek and implement federal waivers
2034necessary to provide for cost-effective purchasing of home
2035health services, private duty nursing services, transportation,
2036independent laboratory services, and durable medical equipment
2037and supplies through competitive bidding pursuant to s. 287.057.
2038The agency may request appropriate waivers from the federal
2039Health Care Financing Administration in order to competitively
2040bid such services. The agency may exclude providers not selected
2041through the bidding process from the Medicaid provider network.
2042     (36)(38)  The agency shall enter into agreements with not-
2043for-profit organizations based in this state for the purpose of
2044providing vision screening. This subsection expires October 1,
2046     (37)(39)(a)  The agency shall implement a Medicaid
2047prescribed-drug spending-control program that includes the
2048following components:
2049     1.  A Medicaid preferred drug list, which shall be a
2050listing of cost-effective therapeutic options recommended by the
2051Medicaid Pharmacy and Therapeutics Committee established
2052pursuant to s. 409.91195 and adopted by the agency for each
2053therapeutic class on the preferred drug list. At the discretion
2054of the committee, and when feasible, the preferred drug list
2055should include at least two products in a therapeutic class. The
2056agency may post the preferred drug list and updates to the
2057preferred drug list on an Internet website without following the
2058rulemaking procedures of chapter 120. Antiretroviral agents are
2059excluded from the preferred drug list. The agency shall also
2060limit the amount of a prescribed drug dispensed to no more than
2061a 34-day supply unless the drug products' smallest marketed
2062package is greater than a 34-day supply, or the drug is
2063determined by the agency to be a maintenance drug in which case
2064a 100-day maximum supply may be authorized. The agency is
2065authorized to seek any federal waivers necessary to implement
2066these cost-control programs and to continue participation in the
2067federal Medicaid rebate program, or alternatively to negotiate
2068state-only manufacturer rebates. The agency may adopt rules to
2069implement this subparagraph. The agency shall continue to
2070provide unlimited contraceptive drugs and items. The agency must
2071establish procedures to ensure that:
2072     a.  There is a response to a request for prior consultation
2073by telephone or other telecommunication device within 24 hours
2074after receipt of a request for prior consultation; and
2075     b.  A 72-hour supply of the drug prescribed is provided in
2076an emergency or when the agency does not provide a response
2077within 24 hours as required by sub-subparagraph a.
2078     2.  Reimbursement to pharmacies for Medicaid prescribed
2079drugs shall be set at the lesser of: the average wholesale price
2080(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2081plus 4.75 percent, the federal upper limit (FUL), the state
2082maximum allowable cost (SMAC), or the usual and customary (UAC)
2083charge billed by the provider.
2084     3.  The agency shall develop and implement a process for
2085managing the drug therapies of Medicaid recipients who are using
2086significant numbers of prescribed drugs each month. The
2087management process may include, but is not limited to,
2088comprehensive, physician-directed medical-record reviews, claims
2089analyses, and case evaluations to determine the medical
2090necessity and appropriateness of a patient's treatment plan and
2091drug therapies. The agency may contract with a private
2092organization to provide drug-program-management services. The
2093Medicaid drug benefit management program shall include
2094initiatives to manage drug therapies for HIV/AIDS patients,
2095patients using 20 or more unique prescriptions in a 180-day
2096period, and the top 1,000 patients in annual spending. The
2097agency shall enroll any Medicaid recipient in the drug benefit
2098management program if he or she meets the specifications of this
2099provision and is not enrolled in a Medicaid health maintenance
2101     4.  The agency may limit the size of its pharmacy network
2102based on need, competitive bidding, price negotiations,
2103credentialing, or similar criteria. The agency shall give
2104special consideration to rural areas in determining the size and
2105location of pharmacies included in the Medicaid pharmacy
2106network. A pharmacy credentialing process may include criteria
2107such as a pharmacy's full-service status, location, size,
2108patient educational programs, patient consultation, disease
2109management services, and other characteristics. The agency may
2110impose a moratorium on Medicaid pharmacy enrollment when it is
2111determined that it has a sufficient number of Medicaid-
2112participating providers. The agency must allow dispensing
2113practitioners to participate as a part of the Medicaid pharmacy
2114network regardless of the practitioner's proximity to any other
2115entity that is dispensing prescription drugs under the Medicaid
2116program. A dispensing practitioner must meet all credentialing
2117requirements applicable to his or her practice, as determined by
2118the agency.
2119     5.  The agency shall develop and implement a program that
2120requires Medicaid practitioners who prescribe drugs to use a
2121counterfeit-proof prescription pad for Medicaid prescriptions.
2122The agency shall require the use of standardized counterfeit-
2123proof prescription pads by Medicaid-participating prescribers or
2124prescribers who write prescriptions for Medicaid recipients. The
2125agency may implement the program in targeted geographic areas or
2127     6.  The agency may enter into arrangements that require
2128manufacturers of generic drugs prescribed to Medicaid recipients
2129to provide rebates of at least 15.1 percent of the average
2130manufacturer price for the manufacturer's generic products.
2131These arrangements shall require that if a generic-drug
2132manufacturer pays federal rebates for Medicaid-reimbursed drugs
2133at a level below 15.1 percent, the manufacturer must provide a
2134supplemental rebate to the state in an amount necessary to
2135achieve a 15.1-percent rebate level.
2136     7.  The agency may establish a preferred drug list as
2137described in this subsection, and, pursuant to the establishment
2138of such preferred drug list, it is authorized to negotiate
2139supplemental rebates from manufacturers that are in addition to
2140those required by Title XIX of the Social Security Act and at no
2141less than 14 percent of the average manufacturer price as
2142defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2143the federal or supplemental rebate, or both, equals or exceeds
214429 percent. There is no upper limit on the supplemental rebates
2145the agency may negotiate. The agency may determine that specific
2146products, brand-name or generic, are competitive at lower rebate
2147percentages. Agreement to pay the minimum supplemental rebate
2148percentage will guarantee a manufacturer that the Medicaid
2149Pharmaceutical and Therapeutics Committee will consider a
2150product for inclusion on the preferred drug list. However, a
2151pharmaceutical manufacturer is not guaranteed placement on the
2152preferred drug list by simply paying the minimum supplemental
2153rebate. Agency decisions will be made on the clinical efficacy
2154of a drug and recommendations of the Medicaid Pharmaceutical and
2155Therapeutics Committee, as well as the price of competing
2156products minus federal and state rebates. The agency is
2157authorized to contract with an outside agency or contractor to
2158conduct negotiations for supplemental rebates. For the purposes
2159of this section, the term "supplemental rebates" means cash
2160rebates. Effective July 1, 2004, value-added programs as a
2161substitution for supplemental rebates are prohibited. The agency
2162is authorized to seek any federal waivers to implement this
2164     8.  The Agency for Health Care Administration shall expand
2165home delivery of pharmacy products. To assist Medicaid patients
2166in securing their prescriptions and reduce program costs, the
2167agency shall expand its current mail-order-pharmacy diabetes-
2168supply program to include all generic and brand-name drugs used
2169by Medicaid patients with diabetes. Medicaid recipients in the
2170current program may obtain nondiabetes drugs on a voluntary
2171basis. This initiative is limited to the geographic area covered
2172by the current contract. The agency may seek and implement any
2173federal waivers necessary to implement this subparagraph.
2174     9.  The agency shall limit to one dose per month any drug
2175prescribed to treat erectile dysfunction.
2176     10.a.  The agency may implement a Medicaid behavioral drug
2177management system. The agency may contract with a vendor that
2178has experience in operating behavioral drug management systems
2179to implement this program. The agency is authorized to seek
2180federal waivers to implement this program.
2181     b.  The agency, in conjunction with the Department of
2182Children and Family Services, may implement the Medicaid
2183behavioral drug management system that is designed to improve
2184the quality of care and behavioral health prescribing practices
2185based on best practice guidelines, improve patient adherence to
2186medication plans, reduce clinical risk, and lower prescribed
2187drug costs and the rate of inappropriate spending on Medicaid
2188behavioral drugs. The program may include the following
2190     (I)  Provide for the development and adoption of best
2191practice guidelines for behavioral health-related drugs such as
2192antipsychotics, antidepressants, and medications for treating
2193bipolar disorders and other behavioral conditions; translate
2194them into practice; review behavioral health prescribers and
2195compare their prescribing patterns to a number of indicators
2196that are based on national standards; and determine deviations
2197from best practice guidelines.
2198     (II)  Implement processes for providing feedback to and
2199educating prescribers using best practice educational materials
2200and peer-to-peer consultation.
2201     (III)  Assess Medicaid beneficiaries who are outliers in
2202their use of behavioral health drugs with regard to the numbers
2203and types of drugs taken, drug dosages, combination drug
2204therapies, and other indicators of improper use of behavioral
2205health drugs.
2206     (IV)  Alert prescribers to patients who fail to refill
2207prescriptions in a timely fashion, are prescribed multiple same-
2208class behavioral health drugs, and may have other potential
2209medication problems.
2210     (V)  Track spending trends for behavioral health drugs and
2211deviation from best practice guidelines.
2212     (VI)  Use educational and technological approaches to
2213promote best practices, educate consumers, and train prescribers
2214in the use of practice guidelines.
2215     (VII)  Disseminate electronic and published materials.
2216     (VIII)  Hold statewide and regional conferences.
2217     (IX)  Implement a disease management program with a model
2218quality-based medication component for severely mentally ill
2219individuals and emotionally disturbed children who are high
2220users of care.
2221     11.a.  The agency shall implement a Medicaid prescription
2222drug management system. The agency may contract with a vendor
2223that has experience in operating prescription drug management
2224systems in order to implement this system. Any management system
2225that is implemented in accordance with this subparagraph must
2226rely on cooperation between physicians and pharmacists to
2227determine appropriate practice patterns and clinical guidelines
2228to improve the prescribing, dispensing, and use of drugs in the
2229Medicaid program. The agency may seek federal waivers to
2230implement this program.
2231     b.  The drug management system must be designed to improve
2232the quality of care and prescribing practices based on best
2233practice guidelines, improve patient adherence to medication
2234plans, reduce clinical risk, and lower prescribed drug costs and
2235the rate of inappropriate spending on Medicaid prescription
2236drugs. The program must:
2237     (I)  Provide for the development and adoption of best
2238practice guidelines for the prescribing and use of drugs in the
2239Medicaid program, including translating best practice guidelines
2240into practice; reviewing prescriber patterns and comparing them
2241to indicators that are based on national standards and practice
2242patterns of clinical peers in their community, statewide, and
2243nationally; and determine deviations from best practice
2245     (II)  Implement processes for providing feedback to and
2246educating prescribers using best practice educational materials
2247and peer-to-peer consultation.
2248     (III)  Assess Medicaid recipients who are outliers in their
2249use of a single or multiple prescription drugs with regard to
2250the numbers and types of drugs taken, drug dosages, combination
2251drug therapies, and other indicators of improper use of
2252prescription drugs.
2253     (IV)  Alert prescribers to patients who fail to refill
2254prescriptions in a timely fashion, are prescribed multiple drugs
2255that may be redundant or contraindicated, or may have other
2256potential medication problems.
2257     (V)  Track spending trends for prescription drugs and
2258deviation from best practice guidelines.
2259     (VI)  Use educational and technological approaches to
2260promote best practices, educate consumers, and train prescribers
2261in the use of practice guidelines.
2262     (VII)  Disseminate electronic and published materials.
2263     (VIII)  Hold statewide and regional conferences.
2264     (IX)  Implement disease management programs in cooperation
2265with physicians and pharmacists, along with a model quality-
2266based medication component for individuals having chronic
2267medical conditions.
2268     12.  The agency is authorized to contract for drug rebate
2269administration, including, but not limited to, calculating
2270rebate amounts, invoicing manufacturers, negotiating disputes
2271with manufacturers, and maintaining a database of rebate
2273     13.  The agency may specify the preferred daily dosing form
2274or strength for the purpose of promoting best practices with
2275regard to the prescribing of certain drugs as specified in the
2276General Appropriations Act and ensuring cost-effective
2277prescribing practices.
2278     14.  The agency may require prior authorization for
2279Medicaid-covered prescribed drugs. The agency may, but is not
2280required to, prior-authorize the use of a product:
2281     a.  For an indication not approved in labeling;
2282     b.  To comply with certain clinical guidelines; or
2283     c.  If the product has the potential for overuse, misuse,
2284or abuse.
2286The agency may require the prescribing professional to provide
2287information about the rationale and supporting medical evidence
2288for the use of a drug. The agency may post prior authorization
2289criteria and protocol and updates to the list of drugs that are
2290subject to prior authorization on an Internet website without
2291amending its rule or engaging in additional rulemaking.
2292     15.  The agency, in conjunction with the Pharmaceutical and
2293Therapeutics Committee, may require age-related prior
2294authorizations for certain prescribed drugs. The agency may
2295preauthorize the use of a drug for a recipient who may not meet
2296the age requirement or may exceed the length of therapy for use
2297of this product as recommended by the manufacturer and approved
2298by the Food and Drug Administration. Prior authorization may
2299require the prescribing professional to provide information
2300about the rationale and supporting medical evidence for the use
2301of a drug.
2302     16.  The agency shall implement a step-therapy prior
2303authorization approval process for medications excluded from the
2304preferred drug list. Medications listed on the preferred drug
2305list must be used within the previous 12 months prior to the
2306alternative medications that are not listed. The step-therapy
2307prior authorization may require the prescriber to use the
2308medications of a similar drug class or for a similar medical
2309indication unless contraindicated in the Food and Drug
2310Administration labeling. The trial period between the specified
2311steps may vary according to the medical indication. The step-
2312therapy approval process shall be developed in accordance with
2313the committee as stated in s. 409.91195(7) and (8). A drug
2314product may be approved without meeting the step-therapy prior
2315authorization criteria if the prescribing physician provides the
2316agency with additional written medical or clinical documentation
2317that the product is medically necessary because:
2318     a.  There is not a drug on the preferred drug list to treat
2319the disease or medical condition which is an acceptable clinical
2321     b.  The alternatives have been ineffective in the treatment
2322of the beneficiary's disease; or
2323     c.  Based on historic evidence and known characteristics of
2324the patient and the drug, the drug is likely to be ineffective,
2325or the number of doses have been ineffective.
2327The agency shall work with the physician to determine the best
2328alternative for the patient. The agency may adopt rules waiving
2329the requirements for written clinical documentation for specific
2330drugs in limited clinical situations.
2331     17.  The agency shall implement a return and reuse program
2332for drugs dispensed by pharmacies to institutional recipients,
2333which includes payment of a $5 restocking fee for the
2334implementation and operation of the program. The return and
2335reuse program shall be implemented electronically and in a
2336manner that promotes efficiency. The program must permit a
2337pharmacy to exclude drugs from the program if it is not
2338practical or cost-effective for the drug to be included and must
2339provide for the return to inventory of drugs that cannot be
2340credited or returned in a cost-effective manner. The agency
2341shall determine if the program has reduced the amount of
2342Medicaid prescription drugs which are destroyed on an annual
2343basis and if there are additional ways to ensure more
2344prescription drugs are not destroyed which could safely be
2345reused. The agency's conclusion and recommendations shall be
2346reported to the Legislature by December 1, 2005.
2347     (b)  The agency shall implement this subsection to the
2348extent that funds are appropriated to administer the Medicaid
2349prescribed-drug spending-control program. The agency may
2350contract all or any part of this program to private
2352     (c)  The agency shall submit quarterly reports to the
2353Governor, the President of the Senate, and the Speaker of the
2354House of Representatives which must include, but need not be
2355limited to, the progress made in implementing this subsection
2356and its effect on Medicaid prescribed-drug expenditures.
2357     (38)(40)  Notwithstanding the provisions of chapter 287,
2358the agency may, at its discretion, renew a contract or contracts
2359for fiscal intermediary services one or more times for such
2360periods as the agency may decide; however, all such renewals may
2361not combine to exceed a total period longer than the term of the
2362original contract.
2363     (39)(41)  The agency shall provide for the development of a
2364demonstration project by establishment in Miami-Dade County of a
2365long-term-care facility licensed pursuant to chapter 395 to
2366improve access to health care for a predominantly minority,
2367medically underserved, and medically complex population and to
2368evaluate alternatives to nursing home care and general acute
2369care for such population. Such project is to be located in a
2370health care condominium and colocated with licensed facilities
2371providing a continuum of care. The establishment of this project
2372is not subject to the provisions of s. 408.036 or s. 408.039.
2373This subsection expires October 1, 2013.
2374     (40)(42)  The agency shall develop and implement a
2375utilization management program for Medicaid-eligible recipients
2376for the management of occupational, physical, respiratory, and
2377speech therapies. The agency shall establish a utilization
2378program that may require prior authorization in order to ensure
2379medically necessary and cost-effective treatments. The program
2380shall be operated in accordance with a federally approved waiver
2381program or state plan amendment. The agency may seek a federal
2382waiver or state plan amendment to implement this program. The
2383agency may also competitively procure these services from an
2384outside vendor on a regional or statewide basis. This subsection
2385expires October 1, 2014.
2386     (41)(43)  The agency shall may contract on a prepaid or
2387fixed-sum basis with appropriately licensed prepaid dental
2388health plans to provide dental services. This subsection expires
2389October 1, 2014.
2390     (42)(44)  The Agency for Health Care Administration shall
2391ensure that any Medicaid managed care plan as defined in s.
2392409.9122(2)(f), whether paid on a capitated basis or a shared
2393savings basis, is cost-effective. For purposes of this
2394subsection, the term "cost-effective" means that a network's
2395per-member, per-month costs to the state, including, but not
2396limited to, fee-for-service costs, administrative costs, and
2397case-management fees, if any, must be no greater than the
2398state's costs associated with contracts for Medicaid services
2399established under subsection (3), which may be adjusted for
2400health status. The agency shall conduct actuarially sound
2401adjustments for health status in order to ensure such cost-
2402effectiveness and shall annually publish the results on its
2403Internet website. Contracts established pursuant to this
2404subsection which are not cost-effective may not be renewed. This
2405subsection expires October 1, 2014.
2406     (43)(45)  Subject to the availability of funds, the agency
2407shall mandate a recipient's participation in a provider lock-in
2408program, when appropriate, if a recipient is found by the agency
2409to have used Medicaid goods or services at a frequency or amount
2410not medically necessary, limiting the receipt of goods or
2411services to medically necessary providers after the 21-day
2412appeal process has ended, for a period of not less than 1 year.
2413The lock-in programs shall include, but are not limited to,
2414pharmacies, medical doctors, and infusion clinics. The
2415limitation does not apply to emergency services and care
2416provided to the recipient in a hospital emergency department.
2417The agency shall seek any federal waivers necessary to implement
2418this subsection. The agency shall adopt any rules necessary to
2419comply with or administer this subsection. This subsection
2420expires October 1, 2014.
2421     (44)(46)  The agency shall seek a federal waiver for
2422permission to terminate the eligibility of a Medicaid recipient
2423who has been found to have committed fraud, through judicial or
2424administrative determination, two times in a period of 5 years.
2425     (47)  The agency shall conduct a study of available
2426electronic systems for the purpose of verifying the identity and
2427eligibility of a Medicaid recipient. The agency shall recommend
2428to the Legislature a plan to implement an electronic
2429verification system for Medicaid recipients by January 31, 2005.
2430     (45)(48)(a)  A provider is not entitled to enrollment in
2431the Medicaid provider network. The agency may implement a
2432Medicaid fee-for-service provider network controls, including,
2433but not limited to, competitive procurement and provider
2434credentialing. If a credentialing process is used, the agency
2435may limit its provider network based upon the following
2436considerations: beneficiary access to care, provider
2437availability, provider quality standards and quality assurance
2438processes, cultural competency, demographic characteristics of
2439beneficiaries, practice standards, service wait times, provider
2440turnover, provider licensure and accreditation history, program
2441integrity history, peer review, Medicaid policy and billing
2442compliance records, clinical and medical record audit findings,
2443and such other areas that are considered necessary by the agency
2444to ensure the integrity of the program.
2445     (b)  The agency shall limit its network of durable medical
2446equipment and medical supply providers. For dates of service
2447after January 1, 2009, the agency shall limit payment for
2448durable medical equipment and supplies to providers that meet
2449all the requirements of this paragraph.
2450     1.  Providers must be accredited by a Centers for Medicare
2451and Medicaid Services deemed accreditation organization for
2452suppliers of durable medical equipment, prosthetics, orthotics,
2453and supplies. The provider must maintain accreditation and is
2454subject to unannounced reviews by the accrediting organization.
2455     2.  Providers must provide the services or supplies
2456directly to the Medicaid recipient or caregiver at the provider
2457location or recipient's residence or send the supplies directly
2458to the recipient's residence with receipt of mailed delivery.
2459Subcontracting or consignment of the service or supply to a
2460third party is prohibited.
2461     3.  Notwithstanding subparagraph 2., a durable medical
2462equipment provider may store nebulizers at a physician's office
2463for the purpose of having the physician's staff issue the
2464equipment if it meets all of the following conditions:
2465     a.  The physician must document the medical necessity and
2466need to prevent further deterioration of the patient's
2467respiratory status by the timely delivery of the nebulizer in
2468the physician's office.
2469     b.  The durable medical equipment provider must have
2470written documentation of the competency and training by a
2471Florida-licensed registered respiratory therapist of any durable
2472medical equipment staff who participate in the training of
2473physician office staff for the use of nebulizers, including
2474cleaning, warranty, and special needs of patients.
2475     c.  The physician's office must have documented the
2476training and competency of any staff member who initiates the
2477delivery of nebulizers to patients. The durable medical
2478equipment provider must maintain copies of all physician office
2480     d.  The physician's office must maintain inventory records
2481of stored nebulizers, including documentation of the durable
2482medical equipment provider source.
2483     e.  A physician contracted with a Medicaid durable medical
2484equipment provider may not have a financial relationship with
2485that provider or receive any financial gain from the delivery of
2486nebulizers to patients.
2487     4.  Providers must have a physical business location and a
2488functional landline business phone. The location must be within
2489the state or not more than 50 miles from the Florida state line.
2490The agency may make exceptions for providers of durable medical
2491equipment or supplies not otherwise available from other
2492enrolled providers located within the state.
2493     5.  Physical business locations must be clearly identified
2494as a business that furnishes durable medical equipment or
2495medical supplies by signage that can be read from 20 feet away.
2496The location must be readily accessible to the public during
2497normal, posted business hours and must operate at least 5 hours
2498per day and at least 5 days per week, with the exception of
2499scheduled and posted holidays. The location may not be located
2500within or at the same numbered street address as another
2501enrolled Medicaid durable medical equipment or medical supply
2502provider or as an enrolled Medicaid pharmacy that is also
2503enrolled as a durable medical equipment provider. A licensed
2504orthotist or prosthetist that provides only orthotic or
2505prosthetic devices as a Medicaid durable medical equipment
2506provider is exempt from this paragraph.
2507     6.  Providers must maintain a stock of durable medical
2508equipment and medical supplies on site that is readily available
2509to meet the needs of the durable medical equipment business
2510location's customers.
2511     7.  Providers must provide a surety bond of $50,000 for
2512each provider location, up to a maximum of 5 bonds statewide or
2513an aggregate bond of $250,000 statewide, as identified by
2514Federal Employer Identification Number. Providers who post a
2515statewide or an aggregate bond must identify all of their
2516locations in any Medicaid durable medical equipment and medical
2517supply provider enrollment application or bond renewal. Each
2518provider location's surety bond must be renewed annually and the
2519provider must submit proof of renewal even if the original bond
2520is a continuous bond. A licensed orthotist or prosthetist that
2521provides only orthotic or prosthetic devices as a Medicaid
2522durable medical equipment provider is exempt from the provisions
2523in this paragraph.
2524     8.  Providers must obtain a level 2 background screening,
2525in accordance with chapter 435 and s. 408.809, for each provider
2526employee in direct contact with or providing direct services to
2527recipients of durable medical equipment and medical supplies in
2528their homes. This requirement includes, but is not limited to,
2529repair and service technicians, fitters, and delivery staff. The
2530provider shall pay for the cost of the background screening.
2531     9.  The following providers are exempt from subparagraphs
25321. and 7.:
2533     a.  Durable medical equipment providers owned and operated
2534by a government entity.
2535     b.  Durable medical equipment providers that are operating
2536within a pharmacy that is currently enrolled as a Medicaid
2537pharmacy provider.
2538     c.  Active, Medicaid-enrolled orthopedic physician groups,
2539primarily owned by physicians, which provide only orthotic and
2540prosthetic devices.
2541     (46)(49)  The agency shall contract with established
2542minority physician networks that provide services to
2543historically underserved minority patients. The networks must
2544provide cost-effective Medicaid services, comply with the
2545requirements to be a MediPass provider, and provide their
2546primary care physicians with access to data and other management
2547tools necessary to assist them in ensuring the appropriate use
2548of services, including inpatient hospital services and
2550     (a)  The agency shall provide for the development and
2551expansion of minority physician networks in each service area to
2552provide services to Medicaid recipients who are eligible to
2553participate under federal law and rules.
2554     (b)  The agency shall reimburse each minority physician
2555network as a fee-for-service provider, including the case
2556management fee for primary care, if any, or as a capitated rate
2557provider for Medicaid services. Any savings shall be shared with
2558the minority physician networks pursuant to the contract.
2559     (c)  For purposes of this subsection, the term "cost-
2560effective" means that a network's per-member, per-month costs to
2561the state, including, but not limited to, fee-for-service costs,
2562administrative costs, and case-management fees, if any, must be
2563no greater than the state's costs associated with contracts for
2564Medicaid services established under subsection (3), which shall
2565be actuarially adjusted for case mix, model, and service area.
2566The agency shall conduct actuarially sound audits adjusted for
2567case mix and model in order to ensure such cost-effectiveness
2568and shall annually publish the audit results on its Internet
2569website. Contracts established pursuant to this subsection which
2570are not cost-effective may not be renewed.
2571     (d)  The agency may apply for any federal waivers needed to
2572implement this subsection.
2574This subsection expires October 1, 2014.
2575     (47)(50)  To the extent permitted by federal law and as
2576allowed under s. 409.906, the agency shall provide reimbursement
2577for emergency mental health care services for Medicaid
2578recipients in crisis stabilization facilities licensed under s.
2579394.875 as long as those services are less expensive than the
2580same services provided in a hospital setting.
2581     (48)(51)  The agency shall work with the Agency for Persons
2582with Disabilities to develop a home and community-based waiver
2583to serve children and adults who are diagnosed with familial
2584dysautonomia or Riley-Day syndrome caused by a mutation of the
2585IKBKAP gene on chromosome 9. The agency shall seek federal
2586waiver approval and implement the approved waiver subject to the
2587availability of funds and any limitations provided in the
2588General Appropriations Act. The agency may adopt rules to
2589implement this waiver program.
2590     (49)(52)  The agency shall implement a program of all-
2591inclusive care for children. The program of all-inclusive care
2592for children shall be established to provide in-home hospice-
2593like support services to children diagnosed with a life-
2594threatening illness and enrolled in the Children's Medical
2595Services network to reduce hospitalizations as appropriate. The
2596agency, in consultation with the Department of Health, may
2597implement the program of all-inclusive care for children after
2598obtaining approval from the Centers for Medicare and Medicaid
2600     (50)(53)  Before seeking an amendment to the state plan for
2601purposes of implementing programs authorized by the Deficit
2602Reduction Act of 2005, the agency shall notify the Legislature.
2603     Section 14.  Section 409.91207, Florida Statutes, is
2605     Section 15.  Paragraphs (e), (l), (p), (w), and (dd) of
2606subsection (3) of section 409.91211, Florida Statutes, are
2607amended to read:
2608     409.91211  Medicaid managed care pilot program.-
2609     (3)  The agency shall have the following powers, duties,
2610and responsibilities with respect to the pilot program:
2611     (e)  To implement policies and guidelines for phasing in
2612financial risk for approved provider service networks that, for
2613purposes of this paragraph, include the Children's Medical
2614Services Network, over the period of the waiver and the
2615extension thereof. These policies and guidelines must include an
2616option for a provider service network to be paid fee-for-service
2617rates. For any provider service network established in a managed
2618care pilot area, the option to be paid fee-for-service rates
2619must include a savings-settlement mechanism that is consistent
2620with s. 409.912(42)(44). This model must be converted to a risk-
2621adjusted capitated rate by the beginning of the final year of
2622operation under the waiver extension, and may be converted
2623earlier at the option of the provider service network. Federally
2624qualified health centers may be offered an opportunity to accept
2625or decline a contract to participate in any provider network for
2626prepaid primary care services.
2627     (l)  To implement a system that prohibits capitated managed
2628care plans, their representatives, and providers employed by or
2629contracted with the capitated managed care plans from recruiting
2630persons eligible for or enrolled in Medicaid, from providing
2631inducements to Medicaid recipients to select a particular
2632capitated managed care plan, and from prejudicing Medicaid
2633recipients against other capitated managed care plans. The
2634system shall require the entity performing choice counseling to
2635determine if the recipient has made a choice of a plan or has
2636opted out because of duress, threats, payment to the recipient,
2637or incentives promised to the recipient by a third party. If the
2638choice counseling entity determines that the decision to choose
2639a plan was unlawfully influenced or a plan violated any of the
2640provisions of s. 409.912(20)(21), the choice counseling entity
2641shall immediately report the violation to the agency's program
2642integrity section for investigation. Verification of choice
2643counseling by the recipient shall include a stipulation that the
2644recipient acknowledges the provisions of this subsection.
2645     (p)  To implement standards for plan compliance, including,
2646but not limited to, standards for quality assurance and
2647performance improvement, standards for peer or professional
2648reviews, grievance policies, and policies for maintaining
2649program integrity. The agency shall develop a data-reporting
2650system, seek input from managed care plans in order to establish
2651requirements for patient-encounter reporting, and ensure that
2652the data reported is accurate and complete.
2653     1.  In performing the duties required under this section,
2654the agency shall work with managed care plans to establish a
2655uniform system to measure and monitor outcomes for a recipient
2656of Medicaid services.
2657     2.  The system shall use financial, clinical, and other
2658criteria based on pharmacy, medical services, and other data
2659that is related to the provision of Medicaid services,
2660including, but not limited to:
2661     a.  The Health Plan Employer Data and Information Set
2662(HEDIS) or measures that are similar to HEDIS.
2663     b.  Member satisfaction.
2664     c.  Provider satisfaction.
2665     d.  Report cards on plan performance and best practices.
2666     e.  Compliance with the requirements for prompt payment of
2667claims under ss. 627.613, 641.3155, and 641.513.
2668     f.  Utilization and quality data for the purpose of
2669ensuring access to medically necessary services, including
2670underutilization or inappropriate denial of services.
2671     3.  The agency shall require the managed care plans that
2672have contracted with the agency to establish a quality assurance
2673system that incorporates the provisions of s. 409.912(26)(27)
2674and any standards, rules, and guidelines developed by the
2676     4.  The agency shall establish an encounter database in
2677order to compile data on health services rendered by health care
2678practitioners who provide services to patients enrolled in
2679managed care plans in the demonstration sites. The encounter
2680database shall:
2681     a.  Collect the following for each type of patient
2682encounter with a health care practitioner or facility,
2684     (I)  The demographic characteristics of the patient.
2685     (II)  The principal, secondary, and tertiary diagnosis.
2686     (III)  The procedure performed.
2687     (IV)  The date and location where the procedure was
2689     (V)  The payment for the procedure, if any.
2690     (VI)  If applicable, the health care practitioner's
2691universal identification number.
2692     (VII)  If the health care practitioner rendering the
2693service is a dependent practitioner, the modifiers appropriate
2694to indicate that the service was delivered by the dependent
2696     b.  Collect appropriate information relating to
2697prescription drugs for each type of patient encounter.
2698     c.  Collect appropriate information related to health care
2699costs and utilization from managed care plans participating in
2700the demonstration sites.
2701     5.  To the extent practicable, when collecting the data the
2702agency shall use a standardized claim form or electronic
2703transfer system that is used by health care practitioners,
2704facilities, and payors.
2705     6.  Health care practitioners and facilities in the
2706demonstration sites shall electronically submit, and managed
2707care plans participating in the demonstration sites shall
2708electronically receive, information concerning claims payments
2709and any other information reasonably related to the encounter
2710database using a standard format as required by the agency.
2711     7.  The agency shall establish reasonable deadlines for
2712phasing in the electronic transmittal of full encounter data.
2713     8.  The system must ensure that the data reported is
2714accurate and complete.
2715     (w)  To implement procedures to minimize the risk of
2716Medicaid fraud and abuse in all plans operating in the Medicaid
2717managed care pilot program authorized in this section.
2718     1.  The agency shall ensure that applicable provisions of
2719this chapter and chapters 414, 626, 641, and 932 which relate to
2720Medicaid fraud and abuse are applied and enforced at the
2721demonstration project sites.
2722     2.  Providers must have the certification, license, and
2723credentials that are required by law and waiver requirements.
2724     3.  The agency shall ensure that the plan is in compliance
2725with s. 409.912(20) and (21) and (22).
2726     4.  The agency shall require that each plan establish
2727functions and activities governing program integrity in order to
2728reduce the incidence of fraud and abuse. Plans must report
2729instances of fraud and abuse pursuant to chapter 641.
2730     5.  The plan shall have written administrative and
2731management arrangements or procedures, including a mandatory
2732compliance plan, which are designed to guard against fraud and
2733abuse. The plan shall designate a compliance officer who has
2734sufficient experience in health care.
2735     6.a.  The agency shall require all managed care plan
2736contractors in the pilot program to report all instances of
2737suspected fraud and abuse. A failure to report instances of
2738suspected fraud and abuse is a violation of law and subject to
2739the penalties provided by law.
2740     b.  An instance of fraud and abuse in the managed care
2741plan, including, but not limited to, defrauding the state health
2742care benefit program by misrepresentation of fact in reports,
2743claims, certifications, enrollment claims, demographic
2744statistics, or patient-encounter data; misrepresentation of the
2745qualifications of persons rendering health care and ancillary
2746services; bribery and false statements relating to the delivery
2747of health care; unfair and deceptive marketing practices; and
2748false claims actions in the provision of managed care, is a
2749violation of law and subject to the penalties provided by law.
2750     c.  The agency shall require that all contractors make all
2751files and relevant billing and claims data accessible to state
2752regulators and investigators and that all such data is linked
2753into a unified system to ensure consistent reviews and
2755     (dd)  To implement service delivery mechanisms within a
2756specialty plan in area 10 to provide behavioral health care
2757services to Medicaid-eligible children whose cases are open for
2758child welfare services in the HomeSafeNet system. These services
2759must be coordinated with community-based care providers as
2760specified in s. 409.1671, where available, and be sufficient to
2761meet the developmental, behavioral, and emotional needs of these
2762children. Children in area 10 who have an open case in the
2763HomeSafeNet system shall be enrolled into the specialty plan.
2764These service delivery mechanisms must be implemented no later
2765than July 1, 2011, in AHCA area 10 in order for the children in
2766AHCA area 10 to remain exempt from the statewide plan under s.
2767409.912(4)(b)5.8. An administrative fee may be paid to the
2768specialty plan for the coordination of services based on the
2769receipt of the state share of that fee being provided through
2770intergovernmental transfers.
2771     Section 16.  Effective October 1, 2014, section 409.91211,
2772Florida Statutes, is repealed.
2773     Section 17.  Section 409.9122, Florida Statutes, is amended
2774to read:
2775     409.9122  Mandatory Medicaid managed care enrollment;
2776programs and procedures.-
2777     (1)  It is the intent of the Legislature that the MediPass
2778program be cost-effective, provide quality health care, and
2779improve access to health services, and that the program be
2780statewide. This subsection expires October 1, 2014.
2781     (2)(a)  The agency shall enroll in a managed care plan or
2782MediPass all Medicaid recipients, except those Medicaid
2783recipients who are: in an institution; enrolled in the Medicaid
2784medically needy program; or eligible for both Medicaid and
2785Medicare. Upon enrollment, individuals will be able to change
2786their managed care option during the 90-day opt out period
2787required by federal Medicaid regulations. The agency is
2788authorized to seek the necessary Medicaid state plan amendment
2789to implement this policy. However, to the extent permitted by
2790federal law, the agency may enroll in a managed care plan or
2791MediPass a Medicaid recipient who is exempt from mandatory
2792managed care enrollment, provided that:
2793     1.  The recipient's decision to enroll in a managed care
2794plan or MediPass is voluntary;
2795     2.  If the recipient chooses to enroll in a managed care
2796plan, the agency has determined that the managed care plan
2797provides specific programs and services which address the
2798special health needs of the recipient; and
2799     3.  The agency receives any necessary waivers from the
2800federal Centers for Medicare and Medicaid Services.
2802The agency shall develop rules to establish policies by which
2803exceptions to the mandatory managed care enrollment requirement
2804may be made on a case-by-case basis. The rules shall include the
2805specific criteria to be applied when making a determination as
2806to whether to exempt a recipient from mandatory enrollment in a
2807managed care plan or MediPass. School districts participating in
2808the certified school match program pursuant to ss. 409.908(21)
2809and 1011.70 shall be reimbursed by Medicaid, subject to the
2810limitations of s. 1011.70(1), for a Medicaid-eligible child
2811participating in the services as authorized in s. 1011.70, as
2812provided for in s. 409.9071, regardless of whether the child is
2813enrolled in MediPass or a managed care plan. Managed care plans
2814shall make a good faith effort to execute agreements with school
2815districts regarding the coordinated provision of services
2816authorized under s. 1011.70. County health departments
2817delivering school-based services pursuant to ss. 381.0056 and
2818381.0057 shall be reimbursed by Medicaid for the federal share
2819for a Medicaid-eligible child who receives Medicaid-covered
2820services in a school setting, regardless of whether the child is
2821enrolled in MediPass or a managed care plan. Managed care plans
2822shall make a good faith effort to execute agreements with county
2823health departments regarding the coordinated provision of
2824services to a Medicaid-eligible child. To ensure continuity of
2825care for Medicaid patients, the agency, the Department of
2826Health, and the Department of Education shall develop procedures
2827for ensuring that a student's managed care plan or MediPass
2828provider receives information relating to services provided in
2829accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2830     (b)  A Medicaid recipient shall not be enrolled in or
2831assigned to a managed care plan or MediPass unless the managed
2832care plan or MediPass has complied with the quality-of-care
2833standards specified in paragraphs (3)(a) and (b), respectively.
2834     (c)  Medicaid recipients shall have a choice of managed
2835care plans or MediPass. The Agency for Health Care
2836Administration, the Department of Health, the Department of
2837Children and Family Services, and the Department of Elderly
2838Affairs shall cooperate to ensure that each Medicaid recipient
2839receives clear and easily understandable information that meets
2840the following requirements:
2841     1.  Explains the concept of managed care, including
2843     2.  Provides information on the comparative performance of
2844managed care plans and MediPass in the areas of quality,
2845credentialing, preventive health programs, network size and
2846availability, and patient satisfaction.
2847     3.  Explains where additional information on each managed
2848care plan and MediPass in the recipient's area can be obtained.
2849     4.  Explains that recipients have the right to choose their
2850managed care coverage at the time they first enroll in Medicaid
2851and again at regular intervals set by the agency. However, if a
2852recipient does not choose a managed care plan or MediPass, the
2853agency will assign the recipient to a managed care plan or
2854MediPass according to the criteria specified in this section.
2855     5.  Explains the recipient's right to complain, file a
2856grievance, or change managed care plans or MediPass providers if
2857the recipient is not satisfied with the managed care plan or
2859     (d)  The agency shall develop a mechanism for providing
2860information to Medicaid recipients for the purpose of making a
2861managed care plan or MediPass selection. Examples of such
2862mechanisms may include, but not be limited to, interactive
2863information systems, mailings, and mass marketing materials.
2864Managed care plans and MediPass providers are prohibited from
2865providing inducements to Medicaid recipients to select their
2866plans or from prejudicing Medicaid recipients against other
2867managed care plans or MediPass providers.
2868     (e)  Medicaid recipients who are already enrolled in a
2869managed care plan or MediPass shall be offered the opportunity
2870to change managed care plans or MediPass providers on a
2871staggered basis, as defined by the agency. All Medicaid
2872recipients shall have 30 days in which to make a choice of
2873managed care plans or MediPass providers. Those Medicaid
2874recipients who do not make a choice shall be assigned in
2875accordance with paragraph (f). To facilitate continuity of care,
2876for a Medicaid recipient who is also a recipient of Supplemental
2877Security Income (SSI), prior to assigning the SSI recipient to a
2878managed care plan or MediPass, the agency shall determine
2879whether the SSI recipient has an ongoing relationship with a
2880MediPass provider or managed care plan, and if so, the agency
2881shall assign the SSI recipient to that MediPass provider or
2882managed care plan. Those SSI recipients who do not have such a
2883provider relationship shall be assigned to a managed care plan
2884or MediPass provider in accordance with paragraph (f).
2885     (f)  If a Medicaid recipient does not choose a managed care
2886plan or MediPass provider, the agency shall assign the Medicaid
2887recipient to a managed care plan or MediPass provider. Medicaid
2888recipients eligible for managed care plan enrollment who are
2889subject to mandatory assignment but who fail to make a choice
2890shall be assigned to managed care plans until an enrollment of
289135 percent in MediPass and 65 percent in managed care plans, of
2892all those eligible to choose managed care, is achieved. Once
2893this enrollment is achieved, the assignments shall be divided in
2894order to maintain an enrollment in MediPass and managed care
2895plans which is in a 35 percent and 65 percent proportion,
2896respectively. Thereafter, assignment of Medicaid recipients who
2897fail to make a choice shall be based proportionally on the
2898preferences of recipients who have made a choice in the previous
2899period. Such proportions shall be revised at least quarterly to
2900reflect an update of the preferences of Medicaid recipients. The
2901agency shall disproportionately assign Medicaid-eligible
2902recipients who are required to but have failed to make a choice
2903of managed care plan or MediPass, including children, and who
2904would be assigned to the MediPass program to the children's
2905networks as described in s. 409.912(4)(g), Children's Medical
2906Services Network as defined in s. 391.021, exclusive provider
2907organizations, provider service networks, minority physician
2908networks, and pediatric emergency department diversion programs
2909authorized by this chapter or the General Appropriations Act, in
2910such manner as the agency deems appropriate, until the agency
2911has determined that the networks and programs have sufficient
2912numbers to be operated economically. For purposes of this
2913paragraph, when referring to assignment, the term "managed care
2914plans" includes health maintenance organizations, exclusive
2915provider organizations, provider service networks, minority
2916physician networks, Children's Medical Services Network, and
2917pediatric emergency department diversion programs authorized by
2918this chapter or the General Appropriations Act. When making
2919assignments, the agency shall take into account the following
2921     1.  A managed care plan has sufficient network capacity to
2922meet the need of members.
2923     2.  The managed care plan or MediPass has previously
2924enrolled the recipient as a member, or one of the managed care
2925plan's primary care providers or MediPass providers has
2926previously provided health care to the recipient.
2927     3.  The agency has knowledge that the member has previously
2928expressed a preference for a particular managed care plan or
2929MediPass provider as indicated by Medicaid fee-for-service
2930claims data, but has failed to make a choice.
2931     4.  The managed care plan's or MediPass primary care
2932providers are geographically accessible to the recipient's
2934     (g)  When more than one managed care plan or MediPass
2935provider meets the criteria specified in paragraph (f), the
2936agency shall make recipient assignments consecutively by family
2938     (h)  The agency may not engage in practices that are
2939designed to favor one managed care plan over another or that are
2940designed to influence Medicaid recipients to enroll in MediPass
2941rather than in a managed care plan or to enroll in a managed
2942care plan rather than in MediPass. This subsection does not
2943prohibit the agency from reporting on the performance of
2944MediPass or any managed care plan, as measured by performance
2945criteria developed by the agency.
2946     (i)  After a recipient has made his or her selection or has
2947been enrolled in a managed care plan or MediPass, the recipient
2948shall have 90 days to exercise the opportunity to voluntarily
2949disenroll and select another managed care plan or MediPass.
2950After 90 days, no further changes may be made except for good
2951cause. Good cause includes, but is not limited to, poor quality
2952of care, lack of access to necessary specialty services, an
2953unreasonable delay or denial of service, or fraudulent
2954enrollment. The agency shall develop criteria for good cause
2955disenrollment for chronically ill and disabled populations who
2956are assigned to managed care plans if more appropriate care is
2957available through the MediPass program. The agency must make a
2958determination as to whether cause exists. However, the agency
2959may require a recipient to use the managed care plan's or
2960MediPass grievance process prior to the agency's determination
2961of cause, except in cases in which immediate risk of permanent
2962damage to the recipient's health is alleged. The grievance
2963process, when utilized, must be completed in time to permit the
2964recipient to disenroll by the first day of the second month
2965after the month the disenrollment request was made. If the
2966managed care plan or MediPass, as a result of the grievance
2967process, approves an enrollee's request to disenroll, the agency
2968is not required to make a determination in the case. The agency
2969must make a determination and take final action on a recipient's
2970request so that disenrollment occurs no later than the first day
2971of the second month after the month the request was made. If the
2972agency fails to act within the specified timeframe, the
2973recipient's request to disenroll is deemed to be approved as of
2974the date agency action was required. Recipients who disagree
2975with the agency's finding that cause does not exist for
2976disenrollment shall be advised of their right to pursue a
2977Medicaid fair hearing to dispute the agency's finding.
2978     (j)  The agency shall apply for a federal waiver from the
2979Centers for Medicare and Medicaid Services to lock eligible
2980Medicaid recipients into a managed care plan or MediPass for 12
2981months after an open enrollment period. After 12 months'
2982enrollment, a recipient may select another managed care plan or
2983MediPass provider. However, nothing shall prevent a Medicaid
2984recipient from changing primary care providers within the
2985managed care plan or MediPass program during the 12-month
2987     (k)  When a Medicaid recipient does not choose a managed
2988care plan or MediPass provider, the agency shall assign the
2989Medicaid recipient to a managed care plan, except in those
2990counties in which there are fewer than two managed care plans
2991accepting Medicaid enrollees, in which case assignment shall be
2992to a managed care plan or a MediPass provider. Medicaid
2993recipients in counties with fewer than two managed care plans
2994accepting Medicaid enrollees who are subject to mandatory
2995assignment but who fail to make a choice shall be assigned to
2996managed care plans until an enrollment of 35 percent in MediPass
2997and 65 percent in managed care plans, of all those eligible to
2998choose managed care, is achieved. Once that enrollment is
2999achieved, the assignments shall be divided in order to maintain
3000an enrollment in MediPass and managed care plans which is in a
300135 percent and 65 percent proportion, respectively. For purposes
3002of this paragraph, when referring to assignment, the term
3003"managed care plans" includes exclusive provider organizations,
3004provider service networks, Children's Medical Services Network,
3005minority physician networks, and pediatric emergency department
3006diversion programs authorized by this chapter or the General
3007Appropriations Act. When making assignments, the agency shall
3008take into account the following criteria:
3009     1.  A managed care plan has sufficient network capacity to
3010meet the need of members.
3011     2.  The managed care plan or MediPass has previously
3012enrolled the recipient as a member, or one of the managed care
3013plan's primary care providers or MediPass providers has
3014previously provided health care to the recipient.
3015     3.  The agency has knowledge that the member has previously
3016expressed a preference for a particular managed care plan or
3017MediPass provider as indicated by Medicaid fee-for-service
3018claims data, but has failed to make a choice.
3019     4.  The managed care plan's or MediPass primary care
3020providers are geographically accessible to the recipient's
3022     5.  The agency has authority to make mandatory assignments
3023based on quality of service and performance of managed care
3025     (l)  Notwithstanding the provisions of chapter 287, the
3026agency may, at its discretion, renew cost-effective contracts
3027for choice counseling services once or more for such periods as
3028the agency may decide. However, all such renewals may not
3029combine to exceed a total period longer than the term of the
3030original contract.
3032This subsection expires October 1, 2014.
3033     (3)(a)  The agency shall establish quality-of-care
3034standards for managed care plans. These standards shall be based
3035upon, but are not limited to:
3036     1.  Compliance with the accreditation requirements as
3037provided in s. 641.512.
3038     2.  Compliance with Early and Periodic Screening,
3039Diagnosis, and Treatment screening requirements.
3040     3.  The percentage of voluntary disenrollments.
3041     4.  Immunization rates.
3042     5.  Standards of the National Committee for Quality
3043Assurance and other approved accrediting bodies.
3044     6.  Recommendations of other authoritative bodies.
3045     7.  Specific requirements of the Medicaid program, or
3046standards designed to specifically assist the unique needs of
3047Medicaid recipients.
3048     8.  Compliance with the health quality improvement system
3049as established by the agency, which incorporates standards and
3050guidelines developed by the Medicaid Bureau of the Health Care
3051Financing Administration as part of the quality assurance reform
3053     (b)  For the MediPass program, the agency shall establish
3054standards which are based upon, but are not limited to:
3055     1.  Quality-of-care standards which are comparable to those
3056required of managed care plans.
3057     2.  Credentialing standards for MediPass providers.
3058     3.  Compliance with Early and Periodic Screening,
3059Diagnosis, and Treatment screening requirements.
3060     4.  Immunization rates.
3061     5.  Specific requirements of the Medicaid program, or
3062standards designed to specifically assist the unique needs of
3063Medicaid recipients.
3065This subsection expires October 1, 2014.
3066     (4)(a)  Each female recipient may select as her primary
3067care provider an obstetrician/gynecologist who has agreed to
3068participate as a MediPass primary care case manager.
3069     (b)  The agency shall establish a complaints and grievance
3070process to assist Medicaid recipients enrolled in the MediPass
3071program to resolve complaints and grievances. The agency shall
3072investigate reports of quality-of-care grievances which remain
3073unresolved to the satisfaction of the enrollee.
3075This subsection expires October 1, 2014.
3076     (5)(a)  The agency shall work cooperatively with the Social
3077Security Administration to identify beneficiaries who are
3078jointly eligible for Medicare and Medicaid and shall develop
3079cooperative programs to encourage these beneficiaries to enroll
3080in a Medicare participating health maintenance organization or
3081prepaid health plans.
3082     (b)  The agency shall work cooperatively with the
3083Department of Elderly Affairs to assess the potential cost-
3084effectiveness of providing MediPass to beneficiaries who are
3085jointly eligible for Medicare and Medicaid on a voluntary choice
3086basis. If the agency determines that enrollment of these
3087beneficiaries in MediPass has the potential for being cost-
3088effective for the state, the agency shall offer MediPass to
3089these beneficiaries on a voluntary choice basis in the counties
3090where MediPass operates.
3092This subsection expires October 1, 2014.
3093     (6)  MediPass enrolled recipients may receive up to 10
3094visits of reimbursable services by participating Medicaid
3095physicians licensed under chapter 460 and up to four visits of
3096reimbursable services by participating Medicaid physicians
3097licensed under chapter 461. Any further visits must be by prior
3098authorization by the MediPass primary care provider. However,
3099nothing in this subsection may be construed to increase the
3100total number of visits or the total amount of dollars per year
3101per person under current Medicaid rules, unless otherwise
3102provided for in the General Appropriations Act. This subsection
3103expires October 1, 2014.
3104     (7)  The agency shall investigate the feasibility of
3105developing managed care plan and MediPass options for the
3106following groups of Medicaid recipients:
3107     (a)  Pregnant women and infants.
3108     (b)  Elderly and disabled recipients, especially those who
3109are at risk of nursing home placement.
3110     (c)  Persons with developmental disabilities.
3111     (d)  Qualified Medicare beneficiaries.
3112     (e)  Adults who have chronic, high-cost medical conditions.
3113     (f)  Adults and children who have mental health problems.
3114     (g)  Other recipients for whom managed care plans and
3115MediPass offer the opportunity of more cost-effective care and
3116greater access to qualified providers.
3117     (8)(a)  The agency shall encourage the development of
3118public and private partnerships to foster the growth of health
3119maintenance organizations and prepaid health plans that will
3120provide high-quality health care to Medicaid recipients.
3121     (b)  Subject to the availability of moneys and any
3122limitations established by the General Appropriations Act or
3123chapter 216, the agency is authorized to enter into contracts
3124with traditional providers of health care to low-income persons
3125to assist such providers with the technical aspects of
3126cooperatively developing Medicaid prepaid health plans.
3127     1.  The agency may contract with disproportionate share
3128hospitals, county health departments, federally initiated or
3129federally funded community health centers, and counties that
3130operate either a hospital or a community clinic.
3131     2.  A contract may not be for more than $100,000 per year,
3132and no contract may be extended with any particular provider for
3133more than 2 years. The contract is intended only as seed or
3134development funding and requires a commitment from the
3135interested party.
3136     3.  A contract must require participation by at least one
3137community health clinic and one disproportionate share hospital.
3138     (7)(9)(a)  The agency shall develop and implement a
3139comprehensive plan to ensure that recipients are adequately
3140informed of their choices and rights under all Medicaid managed
3141care programs and that Medicaid managed care programs meet
3142acceptable standards of quality in patient care, patient
3143satisfaction, and financial solvency.
3144     (b)  The agency shall provide adequate means for informing
3145patients of their choice and rights under a managed care plan at
3146the time of eligibility determination.
3147     (c)  The agency shall require managed care plans and
3148MediPass providers to demonstrate and document plans and
3149activities, as defined by rule, including outreach and followup,
3150undertaken to ensure that Medicaid recipients receive the health
3151care service to which they are entitled.
3153This subsection expires October 1, 2014.
3154     (8)(10)  The agency shall consult with Medicaid consumers
3155and their representatives on an ongoing basis regarding
3156measurements of patient satisfaction, procedures for resolving
3157patient grievances, standards for ensuring quality of care,
3158mechanisms for providing patient access to services, and
3159policies affecting patient care. This subsection expires October
31601, 2014.
3161     (9)(11)  The agency may extend eligibility for Medicaid
3162recipients enrolled in licensed and accredited health
3163maintenance organizations for the duration of the enrollment
3164period or for 6 months, whichever is earlier, provided the
3165agency certifies that such an offer will not increase state
3166expenditures. This subsection expires October 1, 2013.
3167     (10)(12)  A managed care plan that has a Medicaid contract
3168shall at least annually review each primary care physician's
3169active patient load and shall ensure that additional Medicaid
3170recipients are not assigned to physicians who have a total
3171active patient load of more than 3,000 patients. As used in this
3172subsection, the term "active patient" means a patient who is
3173seen by the same primary care physician, or by a physician
3174assistant or advanced registered nurse practitioner under the
3175supervision of the primary care physician, at least three times
3176within a calendar year. Each primary care physician shall
3177annually certify to the managed care plan whether or not his or
3178her patient load exceeds the limits established under this
3179subsection and the managed care plan shall accept such
3180certification on face value as compliance with this subsection.
3181The agency shall accept the managed care plan's representations
3182that it is in compliance with this subsection based on the
3183certification of its primary care physicians, unless the agency
3184has an objective indication that access to primary care is being
3185compromised, such as receiving complaints or grievances relating
3186to access to care. If the agency determines that an objective
3187indication exists that access to primary care is being
3188compromised, it may verify the patient load certifications
3189submitted by the managed care plan's primary care physicians and
3190that the managed care plan is not assigning Medicaid recipients
3191to primary care physicians who have an active patient load of
3192more than 3,000 patients. This subsection expires October 1,
3194     (11)(13)  Effective July 1, 2003, the agency shall adjust
3195the enrollee assignment process of Medicaid managed prepaid
3196health plans for those Medicaid managed prepaid plans operating
3197in Miami-Dade County which have executed a contract with the
3198agency for a minimum of 8 consecutive years in order for the
3199Medicaid managed prepaid plan to maintain a minimum enrollment
3200level of 15,000 members per month. When assigning enrollees
3201pursuant to this subsection, the agency shall give priority to
3202providers that initially qualified under this subsection until
3203such providers reach and maintain an enrollment level of 15,000
3204members per month. A prepaid health plan that has a statewide
3205Medicaid enrollment of 25,000 or more members is not eligible
3206for enrollee assignments under this subsection. This subsection
3207expires October 1, 2014.
3208     (12)(14)  The agency shall include in its calculation of
3209the hospital inpatient component of a Medicaid health
3210maintenance organization's capitation rate any special payments,
3211including, but not limited to, upper payment limit or
3212disproportionate share hospital payments, made to qualifying
3213hospitals through the fee-for-service program. The agency may
3214seek federal waiver approval or state plan amendment as needed
3215to implement this adjustment.
3216     (13)  The agency shall develop a process to enable any
3217recipient with access to employer-sponsored health care coverage
3218to opt out of all eligible plans in the Medicaid program and to
3219use Medicaid financial assistance to pay for the recipient's
3220share of cost in any such employer-sponsored coverage.
3221Contingent on federal approval, the agency shall also enable
3222recipients with access to other insurance or related products
3223that provide access to health care services created pursuant to
3224state law, including any plan or product available pursuant to
3225the Florida Health Choices Program or any health exchange, to
3226opt out. The amount of financial assistance provided for each
3227recipient may not exceed the amount of the Medicaid premium that
3228would have been paid to a plan for that recipient.
3229     (14)  The agency shall maintain and operate the Medicaid
3230Encounter Data System to collect, process, store, and report on
3231covered services provided to all Florida Medicaid recipients
3232enrolled in prepaid managed care plans.
3233     (a)  Prepaid managed care plans shall submit encounter data
3234electronically in a format that complies with the Health
3235Insurance Portability and Accountability Act provisions for
3236electronic claims and in accordance with deadlines established
3237by the agency. Prepaid managed care plans must certify that the
3238data reported is accurate and complete.
3239     (b)  The agency is responsible for validating the data
3240submitted by the plans. The agency shall develop methods and
3241protocols for ongoing analysis of the encounter data that
3242adjusts for differences in characteristics of prepaid plan
3243enrollees to allow comparison of service utilization among plans
3244and against expected levels of use. The analysis shall be used
3245to identify possible cases of systemic underutilization or
3246denials of claims and inappropriate service utilization such as
3247higher-than-expected emergency department encounters. The
3248analysis shall provide periodic feedback to the plans and enable
3249the agency to establish corrective action plans when necessary.
3250One of the focus areas for the analysis shall be the use of
3251prescription drugs.
3252     (15)  The agency may establish a per-member, per-month
3253payment for Medicare Advantage Special Needs members that are
3254also eligible for Medicaid as a mechanism for meeting the
3255state's cost-sharing obligation. The agency may also develop a
3256per-member, per-month payment only for Medicaid-covered services
3257for which the state is responsible. The agency shall develop a
3258mechanism to ensure that such per-member, per-month payment
3259enhances the value to the state and enrolled members by limiting
3260cost sharing, enhances the scope of Medicare supplemental
3261benefits that are equal to or greater than Medicaid coverage for
3262select services, and improves care coordination.
3263     (16)  The agency shall establish, and managed care plans
3264shall use, a uniform method of accounting for and reporting
3265medical and nonmedical costs. The agency shall make such
3266information available to the public.
3267     (17)  The agency may, on a case-by-case basis, exempt a
3268recipient from mandatory enrollment in a managed care plan when
3269the recipient has a unique, time-limited disease or condition-
3270related circumstance and managed care enrollment will interfere
3271with ongoing care because the recipient's provider does not
3272participate in the managed care plans available in the
3273recipient's area.
3274     (18)  The agency shall contract with a single provider
3275service network to function as a third-party administrator and
3276managing entity for the MediPass program in all counties with
3277fewer than two prepaid plans. The contractor may earn an
3278administrative fee, if the fee is less than any savings
3279determined by the reconciliation process pursuant to s.
3280409.912(4)(d)1. This subsection expires October 1, 2014, or upon
3281full implementation of the managed medical assistance program,
3282whichever is sooner.
3283     (19)  Subject to federal approval, the agency shall
3284contract with a single provider service network to function as a
3285third-party administrator and managing entity for the Medically
3286Needy program in all counties. The contractor shall provide care
3287coordination and utilization management in order to achieve more
3288cost-effective services for Medically Needy enrollees. To
3289facilitate the care management functions of the provider service
3290network, enrollment in the network shall be for a continuous 6-
3291month period or until the end of the contract between the
3292provider service network and the agency, whichever is sooner.
3293Beginning the second month after the determination of
3294eligibility, the contractor may collect a monthly premium from
3295each Medically Needy recipient provided the premium does not
3296exceed the enrollee's share of cost as determined by the
3297Department of Children and Family Services. The contractor must
3298provide a 90-day grace period before disenrolling a Medically
3299Needy recipient for failure to pay premiums. The contractor may
3300earn an administrative fee, if the fee is less than any savings
3301determined by the reconciliation process pursuant to s.
3302409.912(4)(d)1. Premium revenue collected from the recipients
3303shall be deducted from the contractor's earned savings. This
3304subsection expires October 1, 2014, or upon full implementation
3305of the managed medical assistance program, whichever is sooner.
3306     Section 18.  Subsection (15) of section 430.04, Florida
3307Statutes, is amended to read:
3308     430.04  Duties and responsibilities of the Department of
3309Elderly Affairs.-The Department of Elderly Affairs shall:
3310     (15)  Administer all Medicaid waivers and programs relating
3311to elders and their appropriations. The waivers include, but are
3312not limited to:
3313     (a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3314established in s. 430.502(7), (8), and (9).
3315     (a)(b)  The Assisted Living for the Frail Elderly Waiver.
3316     (b)(c)  The Aged and Disabled Adult Waiver.
3317     (c)(d)  The Adult Day Health Care Waiver.
3318     (d)(e)  The Consumer-Directed Care Plus Program as defined
3319in s. 409.221.
3320     (e)(f)  The Program of All-inclusive Care for the Elderly.
3321     (f)(g)  The Long-Term Care Community-Based Diversion Pilot
3322Project as described in s. 430.705.
3323     (g)(h)  The Channeling Services Waiver for Frail Elders.
3325The department shall develop a transition plan for recipients
3326receiving services in long-term care Medicaid waivers for elders
3327or disabled adults on the date eligible plans become available
3328in each recipient's region defined in s. 409.981(2) to enroll
3329those recipients in eligible plans. This subsection expires
3330October 1, 2014.
3331     Section 19.  Section 430.2053, Florida Statutes, is amended
3332to read:
3333     430.2053  Aging resource centers.-
3334     (1)  The department, in consultation with the Agency for
3335Health Care Administration and the Department of Children and
3336Family Services, shall develop pilot projects for aging resource
3337centers. By October 31, 2004, the department, in consultation
3338with the agency and the Department of Children and Family
3339Services, shall develop an implementation plan for aging
3340resource centers and submit the plan to the Governor, the
3341President of the Senate, and the Speaker of the House of
3342Representatives. The plan must include qualifications for
3343designation as a center, the functions to be performed by each
3344center, and a process for determining that a current area agency
3345on aging is ready to assume the functions of an aging resource
3347     (2)  Each area agency on aging shall develop, in
3348consultation with the existing community care for the elderly
3349lead agencies within their planning and service areas, a
3350proposal that describes the process the area agency on aging
3351intends to undertake to transition to an aging resource center
3352prior to July 1, 2005, and that describes the area agency's
3353compliance with the requirements of this section. The proposals
3354must be submitted to the department prior to December 31, 2004.
3355The department shall evaluate all proposals for readiness and,
3356prior to March 1, 2005, shall select three area agencies on
3357aging which meet the requirements of this section to begin the
3358transition to aging resource centers. Those area agencies on
3359aging which are not selected to begin the transition to aging
3360resource centers shall, in consultation with the department and
3361the existing community care for the elderly lead agencies within
3362their planning and service areas, amend their proposals as
3363necessary and resubmit them to the department prior to July 1,
33642005. The department may transition additional area agencies to
3365aging resource centers as it determines that area agencies are
3366in compliance with the requirements of this section.
3367     (3)  The Auditor General and the Office of Program Policy
3368Analysis and Government Accountability (OPPAGA) shall jointly
3369review and assess the department's process for determining an
3370area agency's readiness to transition to an aging resource
3372     (a)  The review must, at a minimum, address the
3373appropriateness of the department's criteria for selection of an
3374area agency to transition to an aging resource center, the
3375instruments applied, the degree to which the department
3376accurately determined each area agency's compliance with the
3377readiness criteria, the quality of the technical assistance
3378provided by the department to an area agency in correcting any
3379weaknesses identified in the readiness assessment, and the
3380degree to which each area agency overcame any identified
3382     (b)  Reports of these reviews must be submitted to the
3383appropriate substantive and appropriations committees in the
3384Senate and the House of Representatives on March 1 and September
33851 of each year until full transition to aging resource centers
3386has been accomplished statewide, except that the first report
3387must be submitted by February 1, 2005, and must address all
3388readiness activities undertaken through December 31, 2004. The
3389perspectives of all participants in this review process must be
3390included in each report.
3391     (2)(4)  The purposes of an aging resource center shall be:
3392     (a)  To provide Florida's elders and their families with a
3393locally focused, coordinated approach to integrating information
3394and referral for all available services for elders with the
3395eligibility determination entities for state and federally
3396funded long-term-care services.
3397     (b)  To provide for easier access to long-term-care
3398services by Florida's elders and their families by creating
3399multiple access points to the long-term-care network that flow
3400through one established entity with wide community recognition.
3401     (3)(5)  The duties of an aging resource center are to:
3402     (a)  Develop referral agreements with local community
3403service organizations, such as senior centers, existing elder
3404service providers, volunteer associations, and other similar
3405organizations, to better assist clients who do not need or do
3406not wish to enroll in programs funded by the department or the
3407agency. The referral agreements must also include a protocol,
3408developed and approved by the department, which provides
3409specific actions that an aging resource center and local
3410community service organizations must take when an elder or an
3411elder's representative seeking information on long-term-care
3412services contacts a local community service organization prior
3413to contacting the aging resource center. The protocol shall be
3414designed to ensure that elders and their families are able to
3415access information and services in the most efficient and least
3416cumbersome manner possible.
3417     (b)  Provide an initial screening of all clients who
3418request long-term-care services to determine whether the person
3419would be most appropriately served through any combination of
3420federally funded programs, state-funded programs, locally funded
3421or community volunteer programs, or private funding for
3423     (c)  Determine eligibility for the programs and services
3424listed in subsection (9) (11) for persons residing within the
3425geographic area served by the aging resource center and
3426determine a priority ranking for services which is based upon
3427the potential recipient's frailty level and likelihood of
3428institutional placement without such services.
3429     (d)  Manage the availability of financial resources for the
3430programs and services listed in subsection (9) (11) for persons
3431residing within the geographic area served by the aging resource
3433     (e)  When financial resources become available, refer a
3434client to the most appropriate entity to begin receiving
3435services. The aging resource center shall make referrals to lead
3436agencies for service provision that ensure that individuals who
3437are vulnerable adults in need of services pursuant to s.
3438415.104(3)(b), or who are victims of abuse, neglect, or
3439exploitation in need of immediate services to prevent further
3440harm and are referred by the adult protective services program,
3441are given primary consideration for receiving community-care-
3442for-the-elderly services in compliance with the requirements of
3443s. 430.205(5)(a) and that other referrals for services are in
3444compliance with s. 430.205(5)(b).
3445     (f)  Convene a work group to advise in the planning,
3446implementation, and evaluation of the aging resource center. The
3447work group shall be comprised of representatives of local
3448service providers, Alzheimer's Association chapters, housing
3449authorities, social service organizations, advocacy groups,
3450representatives of clients receiving services through the aging
3451resource center, and any other persons or groups as determined
3452by the department. The aging resource center, in consultation
3453with the work group, must develop annual program improvement
3454plans that shall be submitted to the department for
3455consideration. The department shall review each annual
3456improvement plan and make recommendations on how to implement
3457the components of the plan.
3458     (g)  Enhance the existing area agency on aging in each
3459planning and service area by integrating, either physically or
3460virtually, the staff and services of the area agency on aging
3461with the staff of the department's local CARES Medicaid nursing
3462home preadmission screening unit and a sufficient number of
3463staff from the Department of Children and Family Services'
3464Economic Self-Sufficiency Unit necessary to determine the
3465financial eligibility for all persons age 60 and older residing
3466within the area served by the aging resource center that are
3467seeking Medicaid services, Supplemental Security Income, and
3468food assistance.
3469     (h)  Assist clients who request long-term care services in
3470being evaluated for eligibility for enrollment in the Medicaid
3471long-term care managed care program as eligible plans become
3472available in each of the regions pursuant to s. 409.981(2).
3473     (i)  Provide choice counseling for the Medicaid long-term
3474care managed care program by integrating, either physically or
3475virtually, choice counseling staff and services as eligible
3476plans become available in each of the regions pursuant to s.
3477409.981(2). Pursuant to s. 409.984(1), the agency may contract
3478directly with the aging resource center to provide choice
3479counseling services or may contract with another vendor if the
3480aging resource center does not choose to provide such services.
3481     (j)  Assist Medicaid recipients enrolled in the Medicaid
3482long-term care managed care program with informally resolving
3483grievances with a managed care network and assist Medicaid
3484recipients in accessing the managed care network's formal
3485grievance process as eligible plans become available in each of
3486the regions defined in s. 409.981(2).
3487     (4)(6)  The department shall select the entities to become
3488aging resource centers based on each entity's readiness and
3489ability to perform the duties listed in subsection (3) (5) and
3490the entity's:
3491     (a)  Expertise in the needs of each target population the
3492center proposes to serve and a thorough knowledge of the
3493providers that serve these populations.
3494     (b)  Strong connections to service providers, volunteer
3495agencies, and community institutions.
3496     (c)  Expertise in information and referral activities.
3497     (d)  Knowledge of long-term-care resources, including
3498resources designed to provide services in the least restrictive
3500     (e)  Financial solvency and stability.
3501     (f)  Ability to collect, monitor, and analyze data in a
3502timely and accurate manner, along with systems that meet the
3503department's standards.
3504     (g)  Commitment to adequate staffing by qualified personnel
3505to effectively perform all functions.
3506     (h)  Ability to meet all performance standards established
3507by the department.
3508     (5)(7)  The aging resource center shall have a governing
3509body which shall be the same entity described in s. 20.41(7),
3510and an executive director who may be the same person as
3511described in s. 20.41(7). The governing body shall annually
3512evaluate the performance of the executive director.
3513     (6)(8)  The aging resource center may not be a provider of
3514direct services other than choice counseling as eligible plans
3515become available in each of the regions defined in s.
3516409.981(2), information and referral services, and screening.
3517     (7)(9)  The aging resource center must agree to allow the
3518department to review any financial information the department
3519determines is necessary for monitoring or reporting purposes,
3520including financial relationships.
3521     (8)(10)  The duties and responsibilities of the community
3522care for the elderly lead agencies within each area served by an
3523aging resource center shall be to:
3524     (a)  Develop strong community partnerships to maximize the
3525use of community resources for the purpose of assisting elders
3526to remain in their community settings for as long as it is
3527safely possible.
3528     (b)  Conduct comprehensive assessments of clients that have
3529been determined eligible and develop a care plan consistent with
3530established protocols that ensures that the unique needs of each
3531client are met.
3532     (9)(11)  The services to be administered through the aging
3533resource center shall include those funded by the following
3535     (a)  Community care for the elderly.
3536     (b)  Home care for the elderly.
3537     (c)  Contracted services.
3538     (d)  Alzheimer's disease initiative.
3539     (e)  Aged and disabled adult Medicaid waiver. This
3540paragraph expires October 1, 2013.
3541     (f)  Assisted living for the frail elderly Medicaid waiver.
3542This paragraph expires October 1, 2013.
3543     (g)  Older Americans Act.
3544     (10)(12)  The department shall, prior to designation of an
3545aging resource center, develop by rule operational and quality
3546assurance standards and outcome measures to ensure that clients
3547receiving services through all long-term-care programs
3548administered through an aging resource center are receiving the
3549appropriate care they require and that contractors and
3550subcontractors are adhering to the terms of their contracts and
3551are acting in the best interests of the clients they are
3552serving, consistent with the intent of the Legislature to reduce
3553the use of and cost of nursing home care. The department shall
3554by rule provide operating procedures for aging resource centers,
3555which shall include:
3556     (a)  Minimum standards for financial operation, including
3557audit procedures.
3558     (b)  Procedures for monitoring and sanctioning of service
3560     (c)  Minimum standards for technology utilized by the aging
3561resource center.
3562     (d)  Minimum staff requirements which shall ensure that the
3563aging resource center employs sufficient quality and quantity of
3564staff to adequately meet the needs of the elders residing within
3565the area served by the aging resource center.
3566     (e)  Minimum accessibility standards, including hours of
3568     (f)  Minimum oversight standards for the governing body of
3569the aging resource center to ensure its continuous involvement
3570in, and accountability for, all matters related to the
3571development, implementation, staffing, administration, and
3572operations of the aging resource center.
3573     (g)  Minimum education and experience requirements for
3574executive directors and other executive staff positions of aging
3575resource centers.
3576     (h)  Minimum requirements regarding any executive staff
3577positions that the aging resource center must employ and minimum
3578requirements that a candidate must meet in order to be eligible
3579for appointment to such positions.
3580     (11)(13)  In an area in which the department has designated
3581an area agency on aging as an aging resource center, the
3582department and the agency shall not make payments for the
3583services listed in subsection (9) (11) and the Long-Term Care
3584Community Diversion Project for such persons who were not
3585screened and enrolled through the aging resource center. The
3586department shall cease making payments for recipients in
3587eligible plans as eligible plans become available in each of the
3588regions defined in s. 409.981(2).
3589     (12)(14)  Each aging resource center shall enter into a
3590memorandum of understanding with the department for
3591collaboration with the CARES unit staff. The memorandum of
3592understanding shall outline the staff person responsible for
3593each function and shall provide the staffing levels necessary to
3594carry out the functions of the aging resource center.
3595     (13)(15)  Each aging resource center shall enter into a
3596memorandum of understanding with the Department of Children and
3597Family Services for collaboration with the Economic Self-
3598Sufficiency Unit staff. The memorandum of understanding shall
3599outline which staff persons are responsible for which functions
3600and shall provide the staffing levels necessary to carry out the
3601functions of the aging resource center.
3602     (14)  As eligible plans become available in each of the
3603regions defined in s. 409.981(2), if an aging resource center
3604does not contract with the agency to provide Medicaid long-term
3605care managed care choice counseling pursuant to s. 409.984(1),
3606the aging resource center shall enter into a memorandum of
3607understanding with the agency to coordinate staffing and
3608collaborate with the choice counseling vendor. The memorandum of
3609understanding shall identify the staff responsible for each
3610function and shall provide the staffing levels necessary to
3611carry out the functions of the aging resource center.
3612     (15)(16)  If any of the state activities described in this
3613section are outsourced, either in part or in whole, the contract
3614executing the outsourcing shall mandate that the contractor or
3615its subcontractors shall, either physically or virtually,
3616execute the provisions of the memorandum of understanding
3617instead of the state entity whose function the contractor or
3618subcontractor now performs.
3619     (16)(17)  In order to be eligible to begin transitioning to
3620an aging resource center, an area agency on aging board must
3621ensure that the area agency on aging which it oversees meets all
3622of the minimum requirements set by law and in rule.
3623     (18)  The department shall monitor the three initial
3624projects for aging resource centers and report on the progress
3625of those projects to the Governor, the President of the Senate,
3626and the Speaker of the House of Representatives by June 30,
36272005. The report must include an evaluation of the
3628implementation process.
3629     (17)(19)(a)  Once an aging resource center is operational,
3630the department, in consultation with the agency, may develop
3631capitation rates for any of the programs administered through
3632the aging resource center. Capitation rates for programs shall
3633be based on the historical cost experience of the state in
3634providing those same services to the population age 60 or older
3635residing within each area served by an aging resource center.
3636Each capitated rate may vary by geographic area as determined by
3637the department.
3638     (b)  The department and the agency may determine for each
3639area served by an aging resource center whether it is
3640appropriate, consistent with federal and state laws and
3641regulations, to develop and pay separate capitated rates for
3642each program administered through the aging resource center or
3643to develop and pay capitated rates for service packages which
3644include more than one program or service administered through
3645the aging resource center.
3646     (c)  Once capitation rates have been developed and
3647certified as actuarially sound, the department and the agency
3648may pay service providers the capitated rates for services when
3650     (d)  The department, in consultation with the agency, shall
3651annually reevaluate and recertify the capitation rates,
3652adjusting forward to account for inflation, programmatic
3654     (20)  The department, in consultation with the agency,
3655shall submit to the Governor, the President of the Senate, and
3656the Speaker of the House of Representatives, by December 1,
36572006, a report addressing the feasibility of administering the
3658following services through aging resource centers beginning July
36591, 2007:
3660     (a)  Medicaid nursing home services.
3661     (b)  Medicaid transportation services.
3662     (c)  Medicaid hospice care services.
3663     (d)  Medicaid intermediate care services.
3664     (e)  Medicaid prescribed drug services.
3665     (f)  Medicaid assistive care services.
3666     (g)  Any other long-term-care program or Medicaid service.
3667     (18)(21)  This section shall not be construed to allow an
3668aging resource center to restrict, manage, or impede the local
3669fundraising activities of service providers.
3670     Section 20.  Effective October 1, 2013, sections 430.701,
3671430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3672430.708, and 430.709, Florida Statutes, are repealed.
3673     Section 21.  Sections 409.9301, 409.942, 409.944, 409.945,
3674409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3675as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3676402.87, Florida Statutes, respectively.
3677     Section 22.  Paragraph (a) of subsection (1) of section
3678443.111, Florida Statutes, is amended to read:
3679     443.111  Payment of benefits.-
3680     (1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3681in accordance with rules adopted by the Agency for Workforce
3682Innovation, subject to the following requirements:
3683     (a)  Benefits are payable by mail or electronically.
3684Notwithstanding s. 402.84(4) s. 409.942(4), the agency may
3685develop a system for the payment of benefits by electronic funds
3686transfer, including, but not limited to, debit cards, electronic
3687payment cards, or any other means of electronic payment that the
3688agency deems to be commercially viable or cost-effective.
3689Commodities or services related to the development of such a
3690system shall be procured by competitive solicitation, unless
3691they are purchased from a state term contract pursuant to s.
3692287.056. The agency shall adopt rules necessary to administer
3693the system.
3694     Section 23.  Subsection (4) of section 641.386, Florida
3695Statutes, is amended to read:
3696     641.386  Agent licensing and appointment required;
3698     (4)  All agents and health maintenance organizations shall
3699comply with and be subject to the applicable provisions of ss.
3700641.309 and 409.912(20)(21), and all companies and entities
3701appointing agents shall comply with s. 626.451, when marketing
3702for any health maintenance organization licensed pursuant to
3703this part, including those organizations under contract with the
3704Agency for Health Care Administration to provide health care
3705services to Medicaid recipients or any private entity providing
3706health care services to Medicaid recipients pursuant to a
3707prepaid health plan contract with the Agency for Health Care
3709     Section 24.  Subsections (6) and (7) of section 766.118,
3710Florida Statutes, are renumbered as subsections (7) and (8),
3711respectively, and a new subsection (6) is added to that section,
3712to read:
3713     766.118  Determination of noneconomic damages.-
3716RECIPIENTS.-Notwithstanding subsections (2), (3), (4), and (5),
3717with respect to a cause of action for personal injury or
3718wrongful death arising from medical negligence of practitioners
3719providing services and care to Medicaid recipients as defined in
3720s. 409.901, regardless of the number of such practitioner
3721defendants providing services and care to Medicaid recipients as
3722defined in s. 409.901, noneconomic damages may not exceed
3723$300,000 per claimant. A practitioner providing services and
3724care to Medicaid recipients as defined in s. 409.901 is not
3725liable for more than $200,000 in noneconomic damages, regardless
3726of the number of claimants.
3727     Section 25.  The Agency for Health Care Administration
3728shall develop a plan for implementing s. 409.975(8), Florida
3729Statutes, and shall immediately seek federal approval to
3730implement that subsection. The plan shall include a preliminary
3731calculation of actuarially sound rates and estimated fiscal
3733     Section 26.  Except as otherwise expressly provided in this
3734act, this act shall take effect July 1, 2011, if HB 7107 or
3735similar legislation is adopted in the same legislative session
3736or an extension thereof and becomes law.

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