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
4collect premiums or cost sharing for a home and community-
5based delivery system; providing that implementation of
6Medicaid waiver programs and services authorized under ch.
7393, F.S., are subject to certain funding limitations;
8requiring that certain provisions relating to agency cost
9containment initiatives be included in contracts with
10independent support coordinators and service providers;
11providing for establishment of agency corrective action
12plans and redesign of the waiver program under certain
13circumstances; requiring the plan to be submitted to the
14Legislature; amending s. 393.063, F.S.; defining the term
15"Down syndrome"; amending s. 408.040, F.S.; prohibiting
16the agency from imposing sanctions related to patient day
17utilization by patients eligible for care under Title XIX
18of the Social Security Act for a nursing home, effective
19on a specified date; amending s. 408.0435, F.S.; extending
20the certificate-of-need moratorium for additional
21community nursing home beds; designating ss. 409.016-
22409.803, F.S., as pt. I of ch. 409, F.S., and entitling
23the part "Social and Economic Assistance"; designating ss.
24409.810-409.821, F.S., as pt. II of ch. 409, F.S., and
25entitling the part "Kidcare"; designating ss. 409.901-
26409.9205, F.S., as part III of ch. 409, F.S., and
27entitling the part "Medicaid"; amending s. 409.9021, F.S.;
28revising the time period during which a Medicaid applicant
29must agree to forfeiture of all entitlements upon a
30judicial or administrative finding of fraud; amending s.
31409.905, F.S.; requiring the Agency for Health Care
32Administration to set reimbursements rates for hospitals
33that provide Medicaid services based on allowable-cost
34reporting from the hospitals; removing requirements for
35prior authorization for the provision of certain services;
36providing the methodology for the rate calculation and
37adjustments; requiring the rates to be subject to certain
38limits or ceilings; authorizing the agency to require
39prior authorization of home health services under certain
40conditions; providing that exemptions to the limits or
41ceilings may be provided in the General Appropriations
42Act; deleting provisions relating to agency adjustments to
43a hospital's inpatient per diem rate; directing the agency
44to develop a plan to convert inpatient hospital rates to a
45prospective payment system that categorizes each case into
46diagnosis-related groups; requiring a report to the
47Governor and Legislature; amending s. 409.906, F.S.;
48providing conditions under which the agency shall seek
49federal approval to develop a system to require payment of
50premiums or other cost sharing by the parents of certain
51children receiving Medicaid home and community-based
52waiver services; authorizing the Department of Children
53and Family Services to collect certain income information;
54requiring a report to the Legislature; amending s.
55409.907, F.S.; providing additional requirements for
56provider agreements for Medicare crossover providers;
57providing that the agency is not obligated to enroll
58certain providers as Medicare crossover providers;
59specifying additional requirements for certain providers;
60providing the agency may establish additional criteria for
61providers to promote program integrity; amending s.
62409.908, F.S.; revising provisions relating to
63reimbursement of Medicaid direct care providers to include
64additional, specified medically necessary care; amending
65s. 409.9081, F.S.; providing conditions for copayments by
66Medicaid recipients for nonemergency care and services
67provided in a hospital emergency; amending s. 409.911,
68F.S.; providing for expiration of the Medicaid Low-Income
69Pool Council; amending s. 409.912, F.S.; providing payment
70requirements for provider service networks; providing for
71the expiration of various provisions relating to agency
72contracts and agreements with certain entities on
73specified dates to conform to the reorganization of
74Medicaid managed care; requiring the agency to contract on
75a prepaid or fixed-sum basis with certain prepaid dental
76health plans; eliminating obsolete provisions and updating
77provisions, to conform; amending ss. 409.91195 and
78409.91196, F.S.; conforming cross-references; repealing s.
79409.91207, F.S., relating to the medical home pilot
80project; amending s. 409.91211, F.S.; conforming cross-
81references; providing for future repeal of s. 409.91211,
82F.S., relating to the Medicaid managed care pilot program;
83amending s. 409.9122, F.S.; providing for the expiration
84of provisions relating to mandatory enrollment in a
85Medicaid managed care plan or MediPass on specified dates
86to conform to the reorganization of Medicaid managed care;
87eliminating obsolete provisions; providing for the agency
88to assign Medicaid recipients with HIV/AIDS in specified
89counties to a managed care plan that is a health
90maintenance organization under certain conditions;
91requiring the agency to develop a process to enable any
92recipient with access to employer-sponsored coverage to
93opt out of eligible plans in the Medicaid program;
94requiring the agency, contingent on federal approval, to
95enable recipients with access to other coverage or related
96products that provide access to specified health care
97services to opt out of eligible plans in the Medicaid
98program; requiring the agency to maintain and operate the
99Medicaid Encounter Data System; requiring the agency to
100conduct a review of encounter data and publish the results
101of the review before adjusting rates for prepaid plans;
102authorizing the agency to establish a designated payment
103for specified Medicare Advantage Special Needs members;
104authorizing the agency to develop a designated payment for
105Medicaid-only covered services for which the state is
106responsible; requiring the agency to establish, and
107managed care plans to use, a uniform method of accounting
108for and reporting medical and nonmedical costs;
109authorizing the agency to create exceptions to mandatory
110enrollment in managed care under specified circumstances;
111requiring the agency to contract with a provider service
112network to function as a third-party administrator and
113managing entity for the MediPass program; providing
114contract provisions; providing for the expiration of such
115contract requirements on a specified date; requiring the
116agency to contract with a single provider service network
117to function as a third-party administrator and managing
118entity for the Medically Needy program; providing contract
119provisions; providing for the expiration of such contract
120requirements on a specified date; amending s. 430.04,
121F.S.; eliminating obsolete provisions; requiring the
122Department of Elderly Affairs to develop a transition plan
123for specified elders and disabled adults receiving long-
124term care Medicaid services when eligible plans become
125available; providing for expiration of the plan; amending
126s. 430.2053, F.S.; eliminating obsolete provisions;
127providing additional duties of aging resource centers;
128providing an additional exception to direct services that
129may not be provided by an aging resource center; providing
130an expiration date for certain services administered
131through aging resource centers; providing for the
132cessation of specified payments by the department as
133eligible plans become available; providing for a
134memorandum of understanding between the agency and aging
135resource centers under certain circumstances; eliminating
136provisions requiring reports; repealing s. 430.701, F.S.,
137relating to legislative findings and intent and approval
138for action relating to provider enrollment levels;
139repealing s. 430.702, F.S., relating to the Long-Term Care
140Community Diversion Pilot Project Act; repealing s.
141430.703, F.S., relating to definitions; repealing s.
142430.7031, F.S., relating to the nursing home transition
143program; repealing s. 430.704, F.S., relating to
144evaluation of long-term care through the pilot projects;
145repealing s. 430.705, F.S., relating to implementation of
146long-term care community diversion pilot projects;
147repealing s. 430.706, F.S., relating to quality of care;
148repealing s. 430.707, F.S., relating to contracts;
149repealing s. 430.708, F.S., relating to certificate of
150need; repealing s. 430.709, F.S., relating to reports and
151evaluations; renumbering ss. 409.9301, 409.942, 409.944,
152409.945, 409.946, 409.953, and 409.9531, F.S., as ss.
153402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
154402.87, F.S., respectively; amending ss. 443.111 and
155641.386, F.S.; conforming cross-references; amending s.
156766.118, F.S.; providing a limitation on noneconomic
157damages for negligence of practitioners providing medical
158services and medical care to Medicaid recipients; defining
159terms for purposes of the limitation; requiring the agency
160to develop a plan to implement and seek federal approval
161for the medically needy program for Medicaid enrollees;
162requiring the agency to develop a reorganization plan for
163realignment of administrative resources of the Medicaid
164program; requiring the plan to be submitted to the
165Governor and Legislature; amending s. 393.0662, F.S.;
166including certain individuals with Down syndrome or a
167developmental disability as eligible to participate in the
168iBudget system; amending s. 409.902, F.S.; restricting
169Medicaid eligibility to citizens of the United States who
170meet certain criteria; amending s. 641.19, F.S.; defining
171the term "provider service network" for purposes of pt. I
172of ch. 641, F.S.; creating s. 641.2019, F.S.; providing
173conditions under which a prepaid provider service network
174may obtain a certificate of authority under s. 641.21,
175F.S.; amending s. 641.2261, F.S.; providing an exception
176for provider service networks from certain federal
177solvency requirements; providing for severability;
178providing effective dates and a contingent effective date.
180Be It Enacted by the Legislature of the State of Florida:
182     Section 1.  Section 393.0661, Florida Statutes, is amended
183to read:
184     393.0661  Home and community-based services delivery
185system; comprehensive redesign.-The Legislature finds that the
186home and community-based services delivery system for persons
187with developmental disabilities and the availability of
188appropriated funds are two of the critical elements in making
189services available. Therefore, it is the intent of the
190Legislature that the Agency for Persons with Disabilities shall
191develop and implement a comprehensive redesign of the system.
192     (1)  The redesign of the home and community-based services
193system shall include, at a minimum, all actions necessary to
194achieve an appropriate rate structure, client choice within a
195specified service package, appropriate assessment strategies, an
196efficient billing process that contains reconciliation and
197monitoring components, and a redefined role for support
198coordinators that avoids potential conflicts of interest and
199ensures that family/client budgets are linked to levels of need.
200     (a)  The agency shall use an assessment instrument that the
201agency deems to be reliable and valid, including, but not
202limited to, the Department of Children and Family Services'
203Individual Cost Guidelines or the agency's Questionnaire for
204Situational Information. The agency may contract with an
205external vendor or may use support coordinators to complete
206client assessments if it develops sufficient safeguards and
207training to ensure ongoing inter-rater reliability.
208     (b)  The agency, with the concurrence of the Agency for
209Health Care Administration, may contract for the determination
210of medical necessity and establishment of individual budgets.
211     (2)  A provider of services rendered to persons with
212developmental disabilities pursuant to a federally approved
213waiver shall be reimbursed according to a rate methodology based
214upon an analysis of the expenditure history and prospective
215costs of providers participating in the waiver program, or under
216any other methodology developed by the Agency for Health Care
217Administration, in consultation with the Agency for Persons with
218Disabilities, and approved by the Federal Government in
219accordance with the waiver.
220     (3)  The Agency for Health Care Administration, in
221consultation with the agency, shall seek federal approval and
222implement a four-tiered waiver system to serve eligible clients
223through the developmental disabilities and family and supported
224living waivers. For the purpose of this waiver program, eligible
225clients shall include individuals with a diagnosis of Down
226syndrome or a developmental disability as defined in s. 393.063.
227The agency shall assign all clients receiving services through
228the developmental disabilities waiver to a tier based on the
229Department of Children and Family Services' Individual Cost
230Guidelines, the agency's Questionnaire for Situational
231Information, or another such assessment instrument deemed to be
232valid and reliable by the agency; client characteristics,
233including, but not limited to, age; and other appropriate
234assessment methods.
235     (a)  Tier one is limited to clients who have service needs
236that cannot be met in tier two, three, or four for intensive
237medical or adaptive needs and that are essential for avoiding
238institutionalization, or who possess behavioral problems that
239are exceptional in intensity, duration, or frequency and present
240a substantial risk of harm to themselves or others. Total annual
241expenditures under tier one may not exceed $150,000 per client
242each year, provided that expenditures for clients in tier one
243with a documented medical necessity requiring intensive
244behavioral residential habilitation services, intensive
245behavioral residential habilitation services with medical needs,
246or special medical home care, as provided in the Developmental
247Disabilities Waiver Services Coverage and Limitations Handbook,
248are not subject to the $150,000 limit on annual expenditures.
249     (b)  Tier two is limited to clients whose service needs
250include a licensed residential facility and who are authorized
251to receive a moderate level of support for standard residential
252habilitation services or a minimal level of support for behavior
253focus residential habilitation services, or clients in supported
254living who receive more than 6 hours a day of in-home support
255services. Total annual expenditures under tier two may not
256exceed $53,625 per client each year.
257     (c)  Tier three includes, but is not limited to, clients
258requiring residential placements, clients in independent or
259supported living situations, and clients who live in their
260family home. Total annual expenditures under tier three may not
261exceed $34,125 per client each year.
262     (d)  Tier four includes individuals who were enrolled in
263the family and supported living waiver on July 1, 2007, who
264shall be assigned to this tier without the assessments required
265by this section. Tier four also includes, but is not limited to,
266clients in independent or supported living situations and
267clients who live in their family home. Total annual expenditures
268under tier four may not exceed $14,422 per client each year.
269     (e)  The Agency for Health Care Administration shall also
270seek federal approval to provide a consumer-directed option for
271persons with developmental disabilities which corresponds to the
272funding levels in each of the waiver tiers. The agency shall
273implement the four-tiered waiver system beginning with tiers
274one, three, and four and followed by tier two. The agency and
275the Agency for Health Care Administration may adopt rules
276necessary to administer this subsection.
277     (f)  The agency shall seek federal waivers and amend
278contracts as necessary to make changes to services defined in
279federal waiver programs administered by the agency as follows:
280     1.  Supported living coaching services may not exceed 20
281hours per month for persons who also receive in-home support
283     2.  Limited support coordination services is the only type
284of support coordination service that may be provided to persons
285under the age of 18 who live in the family home.
286     3.  Personal care assistance services are limited to 180
287hours per calendar month and may not include rate modifiers.
288Additional hours may be authorized for persons who have
289intensive physical, medical, or adaptive needs if such hours are
290essential for avoiding institutionalization.
291     4.  Residential habilitation services are limited to 8
292hours per day. Additional hours may be authorized for persons
293who have intensive medical or adaptive needs and if such hours
294are essential for avoiding institutionalization, or for persons
295who possess behavioral problems that are exceptional in
296intensity, duration, or frequency and present a substantial risk
297of harming themselves or others. This restriction shall be in
298effect until the four-tiered waiver system is fully implemented.
299     5.  Chore services, nonresidential support services, and
300homemaker services are eliminated. The agency shall expand the
301definition of in-home support services to allow the service
302provider to include activities previously provided in these
303eliminated services.
304     6.  Massage therapy, medication review, and psychological
305assessment services are eliminated.
306     7.  The agency shall conduct supplemental cost plan reviews
307to verify the medical necessity of authorized services for plans
308that have increased by more than 8 percent during either of the
3092 preceding fiscal years.
310     8.  The agency shall implement a consolidated residential
311habilitation rate structure to increase savings to the state
312through a more cost-effective payment method and establish
313uniform rates for intensive behavioral residential habilitation
315     9.  Pending federal approval, the agency may extend current
316support plans for clients receiving services under Medicaid
317waivers for 1 year beginning July 1, 2007, or from the date
318approved, whichever is later. Clients who have a substantial
319change in circumstances which threatens their health and safety
320may be reassessed during this year in order to determine the
321necessity for a change in their support plan.
322     10.  The agency shall develop a plan to eliminate
323redundancies and duplications between in-home support services,
324companion services, personal care services, and supported living
325coaching by limiting or consolidating such services.
326     11.  The agency shall develop a plan to reduce the
327intensity and frequency of supported employment services to
328clients in stable employment situations who have a documented
329history of at least 3 years' employment with the same company or
330in the same industry.
331     (4)  The geographic differential for Miami-Dade, Broward,
332and Palm Beach Counties for residential habilitation services
333shall be 7.5 percent.
334     (5)  The geographic differential for Monroe County for
335residential habilitation services shall be 20 percent.
336     (6)  Effective January 1, 2010, and except as otherwise
337provided in this section, a client served by the home and
338community-based services waiver or the family and supported
339living waiver funded through the agency shall have his or her
340cost plan adjusted to reflect the amount of expenditures for the
341previous state fiscal year plus 5 percent if such amount is less
342than the client's existing cost plan. The agency shall use
343actual paid claims for services provided during the previous
344fiscal year that are submitted by October 31 to calculate the
345revised cost plan amount. If the client was not served for the
346entire previous state fiscal year or there was any single change
347in the cost plan amount of more than 5 percent during the
348previous state fiscal year, the agency shall set the cost plan
349amount at an estimated annualized expenditure amount plus 5
350percent. The agency shall estimate the annualized expenditure
351amount by calculating the average of monthly expenditures,
352beginning in the fourth month after the client enrolled,
353interrupted services are resumed, or the cost plan was changed
354by more than 5 percent and ending on August 31, 2009, and
355multiplying the average by 12. In order to determine whether a
356client was not served for the entire year, the agency shall
357include any interruption of a waiver-funded service or services
358lasting at least 18 days. If at least 3 months of actual
359expenditure data are not available to estimate annualized
360expenditures, the agency may not rebase a cost plan pursuant to
361this subsection. The agency may not rebase the cost plan of any
362client who experiences a significant change in recipient
363condition or circumstance which results in a change of more than
3645 percent to his or her cost plan between July 1 and the date
365that a rebased cost plan would take effect pursuant to this
367     (7)  The agency shall collect premiums or cost sharing
368pursuant to s. 409.906(13)(d).
369     (8)(7)  Nothing in This section or related in any
370administrative rule does not shall be construed to prevent or
371limit the Agency for Health Care Administration, in consultation
372with the Agency for Persons with Disabilities, from adjusting
373fees, reimbursement rates, lengths of stay, number of visits, or
374number of services, or from limiting enrollment, or making any
375other adjustment necessary to comply with the availability of
376moneys and any limitations or directions provided for in the
377General Appropriations Act.
378     (9)(8)  The Agency for Persons with Disabilities shall
379submit quarterly status reports to the Executive Office of the
380Governor, the chair of the Senate Ways and Means Committee or
381its successor, and the chair of the House Fiscal Council or its
382successor regarding the financial status of home and community-
383based services, including the number of enrolled individuals who
384are receiving services through one or more programs; the number
385of individuals who have requested services who are not enrolled
386but who are receiving services through one or more programs,
387with a description indicating the programs from which the
388individual is receiving services; the number of individuals who
389have refused an offer of services but who choose to remain on
390the list of individuals waiting for services; the number of
391individuals who have requested services but who are receiving no
392services; a frequency distribution indicating the length of time
393individuals have been waiting for services; and information
394concerning the actual and projected costs compared to the amount
395of the appropriation available to the program and any projected
396surpluses or deficits. If at any time an analysis by the agency,
397in consultation with the Agency for Health Care Administration,
398indicates that the cost of services is expected to exceed the
399amount appropriated, the agency shall submit a plan in
400accordance with subsection (8) (7) to the Executive Office of
401the Governor, the chair of the Senate Ways and Means Committee
402or its successor, and the chair of the House Fiscal Council or
403its successor to remain within the amount appropriated. The
404agency shall work with the Agency for Health Care Administration
405to implement the plan so as to remain within the appropriation.
406     (10)  Implementation of Medicaid waiver programs and
407services authorized under this chapter is limited by the funds
408appropriated for the individual budgets pursuant to s. 393.0662
409and the four-tiered waiver system pursuant to subsection (3).
410Contracts with independent support coordinators and service
411providers must include provisions requiring compliance with
412agency cost containment initiatives. The agency shall implement
413monitoring and accounting procedures necessary to track actual
414expenditures and project future spending compared to available
415appropriations for Medicaid waiver programs. When necessary
416based on projected deficits, the agency must establish specific
417corrective action plans that incorporate corrective actions of
418contracted providers that are sufficient to align program
419expenditures with annual appropriations. If deficits continue
420during the 2012-2013 fiscal year, the agency in conjunction with
421the Agency for Health Care Administration shall develop a plan
422to redesign the waiver program and submit the plan to the
423President of the Senate and the Speaker of the House of
424Representatives by September 30, 2013. At a minimum, the plan
425must include the following elements:
426     (a)  Budget predictability.-Agency budget recommendations
427must include specific steps to restrict spending to budgeted
428amounts based on alternatives to the iBudget and four-tiered
429Medicaid waiver models.
430     (b)  Services.-The agency shall identify core services that
431are essential to provide for client health and safety and
432recommend elimination of coverage for other services that are
433not affordable based on available resources.
434     (c)  Flexibility.-The redesign shall be responsive to
435individual needs and to the extent possible encourage client
436control over allocated resources for their needs.
437     (d)  Support coordination services.-The plan shall modify
438the manner of providing support coordination services to improve
439management of service utilization and increase accountability
440and responsiveness to agency priorities.
441     (e)  Reporting.-The agency shall provide monthly reports to
442the President of the Senate and the Speaker of the House of
443Representatives on plan progress and development on July 31,
4442013, and August 31, 2013.
445     (f)  Implementation.-The implementation of a redesigned
446program is subject to legislative approval and shall occur no
447later than July 1, 2014. The Agency for Health Care
448Administration shall seek federal waivers as needed to implement
449the redesigned plan approved by the Legislature.
450     Section 2.  Subsections (13) through (40) of section
451393.063, Florida Statutes, are renumbered as subsections (14)
452through (41), respectively, and a new subsection (13) is added
453to that section to read:
454     393.063  Definitions.-For the purposes of this chapter, the
456     (13)  "Down syndrome" means a disorder caused by the
457presence of an extra chromosome 21.
458     Section 3.  Paragraph (e) of subsection (1) of section
459408.040, Florida Statutes, is redesignated as paragraph (d), and
460paragraph (b) and present paragraph (d) of that subsection are
461amended to read:
462     408.040  Conditions and monitoring.-
463     (1)
464     (b)  The agency may consider, in addition to the other
465criteria specified in s. 408.035, a statement of intent by the
466applicant that a specified percentage of the annual patient days
467at the facility will be utilized by patients eligible for care
468under Title XIX of the Social Security Act. Any certificate of
469need issued to a nursing home in reliance upon an applicant's
470statements that a specified percentage of annual patient days
471will be utilized by residents eligible for care under Title XIX
472of the Social Security Act must include a statement that such
473certification is a condition of issuance of the certificate of
474need. The certificate-of-need program shall notify the Medicaid
475program office and the Department of Elderly Affairs when it
476imposes conditions as authorized in this paragraph in an area in
477which a community diversion pilot project is implemented.
478Effective July 1, 2012, the agency may not impose sanctions
479related to patient day utilization by patients eligible for care
480under Title XIX of the Social Security Act for nursing homes.
481     (d)  If a nursing home is located in a county in which a
482long-term care community diversion pilot project has been
483implemented under s. 430.705 or in a county in which an
484integrated, fixed-payment delivery program for Medicaid
485recipients who are 60 years of age or older or dually eligible
486for Medicare and Medicaid has been implemented under s.
487409.912(5), the nursing home may request a reduction in the
488percentage of annual patient days used by residents who are
489eligible for care under Title XIX of the Social Security Act,
490which is a condition of the nursing home's certificate of need.
491The agency shall automatically grant the nursing home's request
492if the reduction is not more than 15 percent of the nursing
493home's annual Medicaid-patient-days condition. A nursing home
494may submit only one request every 2 years for an automatic
495reduction. A requesting nursing home must notify the agency in
496writing at least 60 days in advance of its intent to reduce its
497annual Medicaid-patient-days condition by not more than 15
498percent. The agency must acknowledge the request in writing and
499must change its records to reflect the revised certificate-of-
500need condition. This paragraph expires June 30, 2011.
501     Section 4.  Subsection (1) of section 408.0435, Florida
502Statutes, is amended to read:
503     408.0435  Moratorium on nursing home certificates of need.-
504     (1)  Notwithstanding the establishment of need as provided
505for in this chapter, a certificate of need for additional
506community nursing home beds may not be approved by the agency
507until Medicaid managed care is implemented statewide pursuant to
508ss. 409.961-409.985 or October 1, 2016, whichever is earlier
509July 1, 2011.
510     Section 5.  Sections 409.016 through 409.803, Florida
511Statutes, are designated as part I of chapter 409, Florida
512Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
513     Section 6.  Sections 409.810 through 409.821, Florida
514Statutes, are designated as part II of chapter 409, Florida
515Statutes, and entitled "KIDCARE."
516     Section 7.  Sections 409.901 through 409.9205, Florida
517Statutes, are designated as part III of chapter 409, Florida
518Statutes, and entitled "MEDICAID."
519     Section 8.  Section 409.9021, Florida Statutes, is amended
520to read:
521     409.9021  Forfeiture of eligibility agreement.-As a
522condition of Medicaid eligibility, subject to federal approval,
523a Medicaid applicant shall agree in writing to forfeit all
524entitlements to any goods or services provided through the
525Medicaid program for the next 10 years if he or she has been
526found to have committed Medicaid fraud, through judicial or
527administrative determination, two times in a period of 5 years.
528This provision applies only to the Medicaid recipient found to
529have committed or participated in Medicaid the fraud and does
530not apply to any family member of the recipient who was not
531involved in the fraud.
532     Section 9.  Subsections (2) and (4) and paragraph (c) of
533subsection (5) of section 409.905, Florida Statutes, are
534amended, and paragraph (g) is added to subsection (5), to read:
535     409.905  Mandatory Medicaid services.-The agency may make
536payments for the following services, which are required of the
537state by Title XIX of the Social Security Act, furnished by
538Medicaid providers to recipients who are determined to be
539eligible on the dates on which the services were provided. Any
540service under this section shall be provided only when medically
541necessary and in accordance with state and federal law.
542Mandatory services rendered by providers in mobile units to
543Medicaid recipients may be restricted by the agency. Nothing in
544this section shall be construed to prevent or limit the agency
545from adjusting fees, reimbursement rates, lengths of stay,
546number of visits, number of services, or any other adjustments
547necessary to comply with the availability of moneys and any
548limitations or directions provided for in the General
549Appropriations Act or chapter 216.
551SERVICES.-The agency shall pay for early and periodic screening
552and diagnosis of a recipient under age 21 to ascertain physical
553and mental problems and conditions and provide treatment to
554correct or ameliorate these problems and conditions. These
555services include all services determined by the agency to be
556medically necessary for the treatment, correction, or
557amelioration of these problems and conditions, including
558personal care, private duty nursing, durable medical equipment,
559physical therapy, occupational therapy, speech therapy,
560respiratory therapy, and immunizations.
561     (4)  HOME HEALTH CARE SERVICES.-The agency shall pay for
562nursing and home health aide services, supplies, appliances, and
563durable medical equipment, necessary to assist a recipient
564living at home. An entity that provides such services must
565pursuant to this subsection shall be licensed under part III of
566chapter 400. These services, equipment, and supplies, or
567reimbursement therefor, may be limited as provided in the
568General Appropriations Act and do not include services,
569equipment, or supplies provided to a person residing in a
570hospital or nursing facility.
571     (a)  In providing home health care services, The agency
572shall may require prior authorization of home health services
573care based on diagnosis, utilization rates, and or billing
574rates. The agency shall require prior authorization for visits
575for home health services that are not associated with a skilled
576nursing visit when the home health agency billing rates exceed
577the state average by 50 percent or more. The home health agency
578must submit the recipient's plan of care and documentation that
579supports the recipient's diagnosis to the agency when requesting
580prior authorization.
581     (b)  The agency shall implement a comprehensive utilization
582management program that requires prior authorization of all
583private duty nursing services, an individualized treatment plan
584that includes information about medication and treatment orders,
585treatment goals, methods of care to be used, and plans for care
586coordination by nurses and other health professionals. The
587utilization management program must shall also include a process
588for periodically reviewing the ongoing use of private duty
589nursing services. The assessment of need shall be based on a
590child's condition;, family support and care supplements;, a
591family's ability to provide care;, and a family's and child's
592schedule regarding work, school, sleep, and care for other
593family dependents; and a determination of the medical necessity
594for private duty nursing instead of other more cost-effective
595in-home services. When implemented, the private duty nursing
596utilization management program shall replace the current
597authorization program used by the agency for Health Care
598Administration and the Children's Medical Services program of
599the Department of Health. The agency may competitively bid on a
600contract to select a qualified organization to provide
601utilization management of private duty nursing services. The
602agency may is authorized to seek federal waivers to implement
603this initiative.
604     (c)  The agency may not pay for home health services unless
605the services are medically necessary and:
606     1.  The services are ordered by a physician.
607     2.  The written prescription for the services is signed and
608dated by the recipient's physician before the development of a
609plan of care and before any request requiring prior
611     3.  The physician ordering the services is not employed,
612under contract with, or otherwise affiliated with the home
613health agency rendering the services. However, this subparagraph
614does not apply to a home health agency affiliated with a
615retirement community, of which the parent corporation or a
616related legal entity owns a rural health clinic certified under
61742 C.F.R. part 491, subpart A, ss. 1-11, a nursing home licensed
618under part II of chapter 400, or an apartment or single-family
619home for independent living. For purposes of this subparagraph,
620the agency may, on a case-by-case basis, provide an exception
621for medically fragile children who are younger than 21 years of
623     4.  The physician ordering the services has examined the
624recipient within the 30 days preceding the initial request for
625the services and biannually thereafter.
626     5.  The written prescription for the services includes the
627recipient's acute or chronic medical condition or diagnosis, the
628home health service required, and, for skilled nursing services,
629the frequency and duration of the services.
630     6.  The national provider identifier, Medicaid
631identification number, or medical practitioner license number of
632the physician ordering the services is listed on the written
633prescription for the services, the claim for home health
634reimbursement, and the prior authorization request.
635     (5)  HOSPITAL INPATIENT SERVICES.-The agency shall pay for
636all covered services provided for the medical care and treatment
637of a recipient who is admitted as an inpatient by a licensed
638physician or dentist to a hospital licensed under part I of
639chapter 395. However, the agency shall limit the payment for
640inpatient hospital services for a Medicaid recipient 21 years of
641age or older to 45 days or the number of days necessary to
642comply with the General Appropriations Act.
643     (c)  The agency shall implement a methodology for
644establishing base reimbursement rates for each hospital based on
645allowable costs, as defined by the agency. Rates shall be
646calculated annually and take effect July 1 of each year based on
647the most recent complete and accurate cost report submitted by
648each hospital. Adjustments may not be made to the rates after
649September 30 of the state fiscal year in which the rate takes
650effect. Errors in cost reporting or calculation of rates
651discovered after September 30 must be reconciled in a subsequent
652rate period. The agency may not make any adjustment to a
653hospital's reimbursement rate more than 5 years after a hospital
654is notified of an audited rate established by the agency. The
655requirement that the agency may not make any adjustment to a
656hospital's reimbursement rate more than 5 years after a hospital
657is notified of an audited rate established by the agency is
658remedial and shall apply to actions by providers involving
659Medicaid claims for hospital services. Hospital rates shall be
660subject to such limits or ceilings as may be established in law
661or described in the agency's hospital reimbursement plan.
662Specific exemptions to the limits or ceilings may be provided in
663the General Appropriations Act. The agency shall adjust a
664hospital's current inpatient per diem rate to reflect the cost
665of serving the Medicaid population at that institution if:
666     1.  The hospital experiences an increase in Medicaid
667caseload by more than 25 percent in any year, primarily
668resulting from the closure of a hospital in the same service
669area occurring after July 1, 1995;
670     2.  The hospital's Medicaid per diem rate is at least 25
671percent below the Medicaid per patient cost for that year; or
672     3.  The hospital is located in a county that has six or
673fewer general acute care hospitals, began offering obstetrical
674services on or after September 1999, and has submitted a request
675in writing to the agency for a rate adjustment after July 1,
6762000, but before September 30, 2000, in which case such
677hospital's Medicaid inpatient per diem rate shall be adjusted to
678cost, effective July 1, 2002.
680By October 1 of each year, the agency must provide estimated
681costs for any adjustment in a hospital inpatient per diem rate
682to the Executive Office of the Governor, the House of
683Representatives General Appropriations Committee, and the Senate
684Appropriations Committee. Before the agency implements a change
685in a hospital's inpatient per diem rate pursuant to this
686paragraph, the Legislature must have specifically appropriated
687sufficient funds in the General Appropriations Act to support
688the increase in cost as estimated by the agency.
689     (g)  The agency shall develop a plan to convert inpatient
690hospital rates to a prospective payment system that categorizes
691each case into diagnosis-related groups (DRG) and assigns a
692payment weight based on the average resources used to treat
693Medicaid patients in that DRG. To the extent possible, the
694agency shall propose an adaptation of an existing prospective
695payment system, such as the one used by Medicare, and shall
696propose such adjustments as are necessary for the Medicaid
697population and to maintain budget neutrality for inpatient
698hospital expenditures. The agency shall submit the Medicaid DRG
699plan, identifying all steps necessary for the transition and any
700costs associated with plan implementation, to the Governor, the
701President of the Senate, and the Speaker of the House of
702Representatives no later than January 1, 2013.
703     Section 10.  Paragraph (d) is added to subsection (13) of
704section 409.906, Florida Statutes, to read:
705     409.906  Optional Medicaid services.-Subject to specific
706appropriations, the agency may make payments for services which
707are optional to the state under Title XIX of the Social Security
708Act and are furnished by Medicaid providers to recipients who
709are determined to be eligible on the dates on which the services
710were provided. Any optional service that is provided shall be
711provided only when medically necessary and in accordance with
712state and federal law. Optional services rendered by providers
713in mobile units to Medicaid recipients may be restricted or
714prohibited by the agency. Nothing in this section shall be
715construed to prevent or limit the agency from adjusting fees,
716reimbursement rates, lengths of stay, number of visits, or
717number of services, or making any other adjustments necessary to
718comply with the availability of moneys and any limitations or
719directions provided for in the General Appropriations Act or
720chapter 216. If necessary to safeguard the state's systems of
721providing services to elderly and disabled persons and subject
722to the notice and review provisions of s. 216.177, the Governor
723may direct the Agency for Health Care Administration to amend
724the Medicaid state plan to delete the optional Medicaid service
725known as "Intermediate Care Facilities for the Developmentally
726Disabled." Optional services may include:
728     (d)  The agency shall request federal approval to develop a
729system to require payment of premiums or other cost sharing by
730the parents of a child who is being served by a waiver under
731this subsection if the adjusted household income is greater than
732100 percent of the federal poverty level. The amount of the
733premium or cost sharing shall be calculated using a sliding
734scale based on the size of the family, the amount of the
735parent's adjusted gross income, and the federal poverty
736guidelines. The premium and cost sharing system developed by the
737agency shall not adversely affect federal funding to the state.
738After the agency receives federal approval, the Department of
739Children and Family Services may collect income information from
740parents of children who will be affected by this paragraph. The
741agency shall prepare a report to include the estimated
742operational cost of implementing the premium and cost sharing
743system and the estimated revenues to be collected from parents
744of children in the waiver program. The report shall be delivered
745to the President of the Senate and the Speaker of the House of
746Representatives by June 30, 2012.
747     Section 11.  Paragraphs (d) and (e) of subsection (5) of
748section 409.907, Florida Statutes, are amended to read:
749     409.907  Medicaid provider agreements.-The agency may make
750payments for medical assistance and related services rendered to
751Medicaid recipients only to an individual or entity who has a
752provider agreement in effect with the agency, who is performing
753services or supplying goods in accordance with federal, state,
754and local law, and who agrees that no person shall, on the
755grounds of handicap, race, color, or national origin, or for any
756other reason, be subjected to discrimination under any program
757or activity for which the provider receives payment from the
759     (5)  The agency:
760     (d)  May enroll entities as Medicare crossover-only
761providers for payment and claims processing purposes only. The
762provider agreement shall:
763     1.  Require that the provider be able to demonstrate to the
764satisfaction of the agency that the provider is an eligible
765Medicare provider and has a current provider agreement in place
766with the Centers for Medicare and Medicaid Services.
767     2.  Require the provider to notify the agency immediately
768in writing upon being suspended or disenrolled as a Medicare
769provider. If the provider does not provide such notification
770within 5 business days after suspension or disenrollment,
771sanctions may be imposed pursuant to this chapter and the
772provider may be required to return funds paid to the provider
773during the period of time that the provider was suspended or
774disenrolled as a Medicare provider.
775     3.  Require the applicant to submit an attestation, as
776approved by the agency, that the provider meets the requirements
777of Florida Medicaid provider enrollment criteria.
778     4.  Require the applicant to submit fingerprints as
779required by the agency.
780     5.3.  Require that all records pertaining to health care
781services provided to each of the provider's recipients be kept
782for a minimum of 6 years. The agreement shall also require that
783records and any information relating to payments claimed by the
784provider for services under the agreement be delivered to the
785agency or the Office of the Attorney General Medicaid Fraud
786Control Unit when requested. If a provider does not provide such
787records and information when requested, sanctions may be imposed
788pursuant to this chapter.
789     6.4.  Disclose that the agreement is for the purposes of
790paying and processing Medicare crossover claims only.
792This paragraph pertains solely to Medicare crossover-only
793providers. In order to become a standard Medicaid provider, the
794requirements of this section and applicable rules must be met.
795This paragraph does not create an entitlement or obligation of
796the agency to enroll all Medicare providers that may be
797considered a Medicare crossover-only provider in the Medicaid
799     (e)  Providers that are required to post a surety bond as
800part of the Medicaid enrollment process are excluded for
801enrollment under paragraph (d) and must complete a full Medicaid
802application. The agency may establish additional criteria to
803promote program integrity.
804     Section 12.  Paragraph (b) of subsection (2) of section
805409.908, Florida Statutes, is amended to read:
806     409.908  Reimbursement of Medicaid providers.-Subject to
807specific appropriations, the agency shall reimburse Medicaid
808providers, in accordance with state and federal law, according
809to methodologies set forth in the rules of the agency and in
810policy manuals and handbooks incorporated by reference therein.
811These methodologies may include fee schedules, reimbursement
812methods based on cost reporting, negotiated fees, competitive
813bidding pursuant to s. 287.057, and other mechanisms the agency
814considers efficient and effective for purchasing services or
815goods on behalf of recipients. If a provider is reimbursed based
816on cost reporting and submits a cost report late and that cost
817report would have been used to set a lower reimbursement rate
818for a rate semester, then the provider's rate for that semester
819shall be retroactively calculated using the new cost report, and
820full payment at the recalculated rate shall be effected
821retroactively. Medicare-granted extensions for filing cost
822reports, if applicable, shall also apply to Medicaid cost
823reports. Payment for Medicaid compensable services made on
824behalf of Medicaid eligible persons is subject to the
825availability of moneys and any limitations or directions
826provided for in the General Appropriations Act or chapter 216.
827Further, nothing in this section shall be construed to prevent
828or limit the agency from adjusting fees, reimbursement rates,
829lengths of stay, number of visits, or number of services, or
830making any other adjustments necessary to comply with the
831availability of moneys and any limitations or directions
832provided for in the General Appropriations Act, provided the
833adjustment is consistent with legislative intent.
834     (2)
835     (b)  Subject to any limitations or directions provided for
836in the General Appropriations Act, the agency shall establish
837and implement a Florida Title XIX Long-Term Care Reimbursement
838Plan (Medicaid) for nursing home care in order to provide care
839and services in conformance with the applicable state and
840federal laws, rules, regulations, and quality and safety
841standards and to ensure that individuals eligible for medical
842assistance have reasonable geographic access to such care.
843     1.  The agency shall amend the long-term care reimbursement
844plan and cost reporting system to create direct care and
845indirect care subcomponents of the patient care component of the
846per diem rate. These two subcomponents together shall equal the
847patient care component of the per diem rate. Separate cost-based
848ceilings shall be calculated for each patient care subcomponent.
849The direct care subcomponent of the per diem rate shall be
850limited by the cost-based class ceiling, and the indirect care
851subcomponent may be limited by the lower of the cost-based class
852ceiling, the target rate class ceiling, or the individual
853provider target.
854     2.  The direct care subcomponent shall include salaries and
855benefits of direct care staff providing nursing services
856including registered nurses, licensed practical nurses, and
857certified nursing assistants who deliver care directly to
858residents in the nursing home facility. This excludes nursing
859administration, minimum data set, and care plan coordinators,
860staff development, and the staffing coordinator. The direct care
861subcomponent also includes medically necessary dental care,
862vision care, hearing care, and podiatric care.
863     3.  All other patient care costs shall be included in the
864indirect care cost subcomponent of the patient care per diem
865rate. There shall be no costs directly or indirectly allocated
866to the direct care subcomponent from a home office or management
868     4.  On July 1 of each year, the agency shall report to the
869Legislature direct and indirect care costs, including average
870direct and indirect care costs per resident per facility and
871direct care and indirect care salaries and benefits per category
872of staff member per facility.
873     5.  In order to offset the cost of general and professional
874liability insurance, the agency shall amend the plan to allow
875for interim rate adjustments to reflect increases in the cost of
876general or professional liability insurance for nursing homes.
877This provision shall be implemented to the extent existing
878appropriations are available.
880It is the intent of the Legislature that the reimbursement plan
881achieve the goal of providing access to health care for nursing
882home residents who require large amounts of care while
883encouraging diversion services as an alternative to nursing home
884care for residents who can be served within the community. The
885agency shall base the establishment of any maximum rate of
886payment, whether overall or component, on the available moneys
887as provided for in the General Appropriations Act. The agency
888may base the maximum rate of payment on the results of
889scientifically valid analysis and conclusions derived from
890objective statistical data pertinent to the particular maximum
891rate of payment.
892     Section 13.  Paragraph (c) of subsection (1) of section
893409.9081, Florida Statutes, is amended to read:
894     409.9081  Copayments.-
895     (1)  The agency shall require, subject to federal
896regulations and limitations, each Medicaid recipient to pay at
897the time of service a nominal copayment for the following
898Medicaid services:
899     (c)  Hospital emergency department visits for nonemergency
900care: 5 percent of up to the first $300 of the Medicaid payment
901for emergency room services, not to exceed $15. The agency shall
902seek federal approval to require Medicaid recipients to pay $100
903copayment for nonemergency services and care furnished in a
904hospital emergency department. Upon waiver approval, a Medicaid
905recipient who requests such services and care must pay a $100
906copayment to the hospital for the nonemergency services and care
907provided in the hospital emergency department.
908     Section 14.  Subsection (10) of section 409.911, Florida
909Statutes, is amended to read:
910     409.911  Disproportionate share program.-Subject to
911specific allocations established within the General
912Appropriations Act and any limitations established pursuant to
913chapter 216, the agency shall distribute, pursuant to this
914section, moneys to hospitals providing a disproportionate share
915of Medicaid or charity care services by making quarterly
916Medicaid payments as required. Notwithstanding the provisions of
917s. 409.915, counties are exempt from contributing toward the
918cost of this special reimbursement for hospitals serving a
919disproportionate share of low-income patients.
920     (10)  The Agency for Health Care Administration shall
921create a Medicaid Low-Income Pool Council by July 1, 2006. The
922Low-Income Pool Council shall consist of 24 members, including 2
923members appointed by the President of the Senate, 2 members
924appointed by the Speaker of the House of Representatives, 3
925representatives of statutory teaching hospitals, 3
926representatives of public hospitals, 3 representatives of
927nonprofit hospitals, 3 representatives of for-profit hospitals,
9282 representatives of rural hospitals, 2 representatives of units
929of local government which contribute funding, 1 representative
930of family practice teaching hospitals, 1 representative of
931federally qualified health centers, 1 representative from the
932Department of Health, and 1 nonvoting representative of the
933Agency for Health Care Administration who shall serve as chair
934of the council. Except for a full-time employee of a public
935entity, an individual who qualifies as a lobbyist under s.
93611.045 or s. 112.3215 may not serve as a member of the council.
937Of the members appointed by the Senate President, only one shall
938be a physician. Of the members appointed by the Speaker of the
939House of Representatives, only one shall be a physician. The
940physician member appointed by the Senate President and the
941physician member appointed by the Speaker of the House of
942Representatives must be physicians who routinely take calls in a
943trauma center, as defined in s. 395.4001, or a hospital
944emergency department. The council shall:
945     (a)  Make recommendations on the financing of the low-
946income pool and the disproportionate share hospital program and
947the distribution of their funds.
948     (b)  Advise the Agency for Health Care Administration on
949the development of the low-income pool plan required by the
950federal Centers for Medicare and Medicaid Services pursuant to
951the Medicaid reform waiver.
952     (c)  Advise the Agency for Health Care Administration on
953the distribution of hospital funds used to adjust inpatient
954hospital rates, rebase rates, or otherwise exempt hospitals from
955reimbursement limits as financed by intergovernmental transfers.
956     (d)  Submit its findings and recommendations to the
957Governor and the Legislature no later than February 1 of each
960This subsection expires October 1, 2014.
961     Section 15.  Subsection (4) of section 409.91195, Florida
962Statutes, is amended to read:
963     409.91195  Medicaid Pharmaceutical and Therapeutics
964Committee.-There is created a Medicaid Pharmaceutical and
965Therapeutics Committee within the agency for the purpose of
966developing a Medicaid preferred drug list.
967     (4)  Upon recommendation of the committee, the agency shall
968adopt a preferred drug list as described in s. 409.912(37)(39).
969To the extent feasible, the committee shall review all drug
970classes included on the preferred drug list every 12 months, and
971may recommend additions to and deletions from the preferred drug
972list, such that the preferred drug list provides for medically
973appropriate drug therapies for Medicaid patients which achieve
974cost savings contained in the General Appropriations Act.
975     Section 16.  Subsection (1) of section 409.91196, Florida
976Statutes, is amended to read:
977     409.91196  Supplemental rebate agreements; public records
978and public meetings exemption.-
979     (1)  The rebate amount, percent of rebate, manufacturer's
980pricing, and supplemental rebate, and other trade secrets as
981defined in s. 688.002 that the agency has identified for use in
982negotiations, held by the Agency for Health Care Administration
983under s. 409.912(37)(39)(a)7. are confidential and exempt from
984s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
985     Section 17.  Section 409.912, Florida Statutes, is amended
986to read:
987     409.912  Cost-effective purchasing of health care.-The
988agency shall purchase goods and services for Medicaid recipients
989in the most cost-effective manner consistent with the delivery
990of quality medical care. To ensure that medical services are
991effectively utilized, the agency may, in any case, require a
992confirmation or second physician's opinion of the correct
993diagnosis for purposes of authorizing future services under the
994Medicaid program. This section does not restrict access to
995emergency services or poststabilization care services as defined
996in 42 C.F.R. part 438.114. Such confirmation or second opinion
997shall be rendered in a manner approved by the agency. The agency
998shall maximize the use of prepaid per capita and prepaid
999aggregate fixed-sum basis services when appropriate and other
1000alternative service delivery and reimbursement methodologies,
1001including competitive bidding pursuant to s. 287.057, designed
1002to facilitate the cost-effective purchase of a case-managed
1003continuum of care. The agency shall also require providers to
1004minimize the exposure of recipients to the need for acute
1005inpatient, custodial, and other institutional care and the
1006inappropriate or unnecessary use of high-cost services. The
1007agency shall contract with a vendor to monitor and evaluate the
1008clinical practice patterns of providers in order to identify
1009trends that are outside the normal practice patterns of a
1010provider's professional peers or the national guidelines of a
1011provider's professional association. The vendor must be able to
1012provide information and counseling to a provider whose practice
1013patterns are outside the norms, in consultation with the agency,
1014to improve patient care and reduce inappropriate utilization.
1015The agency may mandate prior authorization, drug therapy
1016management, or disease management participation for certain
1017populations of Medicaid beneficiaries, certain drug classes, or
1018particular drugs to prevent fraud, abuse, overuse, and possible
1019dangerous drug interactions. The Pharmaceutical and Therapeutics
1020Committee shall make recommendations to the agency on drugs for
1021which prior authorization is required. The agency shall inform
1022the Pharmaceutical and Therapeutics Committee of its decisions
1023regarding drugs subject to prior authorization. The agency is
1024authorized to limit the entities it contracts with or enrolls as
1025Medicaid providers by developing a provider network through
1026provider credentialing. The agency may competitively bid single-
1027source-provider contracts if procurement of goods or services
1028results in demonstrated cost savings to the state without
1029limiting access to care. The agency may limit its network based
1030on the assessment of beneficiary access to care, provider
1031availability, provider quality standards, time and distance
1032standards for access to care, the cultural competence of the
1033provider network, demographic characteristics of Medicaid
1034beneficiaries, practice and provider-to-beneficiary standards,
1035appointment wait times, beneficiary use of services, provider
1036turnover, provider profiling, provider licensure history,
1037previous program integrity investigations and findings, peer
1038review, provider Medicaid policy and billing compliance records,
1039clinical and medical record audits, and other factors. Providers
1040are shall not be entitled to enrollment in the Medicaid provider
1041network. The agency shall determine instances in which allowing
1042Medicaid beneficiaries to purchase durable medical equipment and
1043other goods is less expensive to the Medicaid program than long-
1044term rental of the equipment or goods. The agency may establish
1045rules to facilitate purchases in lieu of long-term rentals in
1046order to protect against fraud and abuse in the Medicaid program
1047as defined in s. 409.913. The agency may seek federal waivers
1048necessary to administer these policies.
1049     (1)  The agency shall work with the Department of Children
1050and Family Services to ensure access of children and families in
1051the child protection system to needed and appropriate mental
1052health and substance abuse services. This subsection expires
1053October 1, 2014.
1054     (2)  The agency may enter into agreements with appropriate
1055agents of other state agencies or of any agency of the Federal
1056Government and accept such duties in respect to social welfare
1057or public aid as may be necessary to implement the provisions of
1058Title XIX of the Social Security Act and ss. 409.901-409.920.
1059This subsection expires October 1, 2016.
1060     (3)  The agency may contract with health maintenance
1061organizations certified pursuant to part I of chapter 641 for
1062the provision of services to recipients. This subsection expires
1063October 1, 2014.
1064     (4)  The agency may contract with:
1065     (a)  An entity that provides no prepaid health care
1066services other than Medicaid services under contract with the
1067agency and which is owned and operated by a county, county
1068health department, or county-owned and operated hospital to
1069provide health care services on a prepaid or fixed-sum basis to
1070recipients, which entity may provide such prepaid services
1071either directly or through arrangements with other providers.
1072Such prepaid health care services entities must be licensed
1073under parts I and III of chapter 641. An entity recognized under
1074this paragraph which demonstrates to the satisfaction of the
1075Office of Insurance Regulation of the Financial Services
1076Commission that it is backed by the full faith and credit of the
1077county in which it is located may be exempted from s. 641.225.
1078This paragraph expires October 1, 2014.
1079     (b)  An entity that is providing comprehensive behavioral
1080health care services to certain Medicaid recipients through a
1081capitated, prepaid arrangement pursuant to the federal waiver
1082provided for by s. 409.905(5). Such entity must be licensed
1083under chapter 624, chapter 636, or chapter 641, or authorized
1084under paragraph (c) or paragraph (d), and must possess the
1085clinical systems and operational competence to manage risk and
1086provide comprehensive behavioral health care to Medicaid
1087recipients. As used in this paragraph, the term "comprehensive
1088behavioral health care services" means covered mental health and
1089substance abuse treatment services that are available to
1090Medicaid recipients. The secretary of the Department of Children
1091and Family Services shall approve provisions of procurements
1092related to children in the department's care or custody before
1093enrolling such children in a prepaid behavioral health plan. Any
1094contract awarded under this paragraph must be competitively
1095procured. In developing the behavioral health care prepaid plan
1096procurement document, the agency shall ensure that the
1097procurement document requires the contractor to develop and
1098implement a plan to ensure compliance with s. 394.4574 related
1099to services provided to residents of licensed assisted living
1100facilities that hold a limited mental health license. Except as
1101provided in subparagraph 5. 8., and except in counties where the
1102Medicaid managed care pilot program is authorized pursuant to s.
1103409.91211, the agency shall seek federal approval to contract
1104with a single entity meeting these requirements to provide
1105comprehensive behavioral health care services to all Medicaid
1106recipients not enrolled in a Medicaid managed care plan
1107authorized under s. 409.91211, a provider service network
1108authorized under paragraph (d), or a Medicaid health maintenance
1109organization in an AHCA area. In an AHCA area where the Medicaid
1110managed care pilot program is authorized pursuant to s.
1111409.91211 in one or more counties, the agency may procure a
1112contract with a single entity to serve the remaining counties as
1113an AHCA area or the remaining counties may be included with an
1114adjacent AHCA area and are subject to this paragraph. Each
1115entity must offer a sufficient choice of providers in its
1116network to ensure recipient access to care and the opportunity
1117to select a provider with whom they are satisfied. The network
1118shall include all public mental health hospitals. To ensure
1119unimpaired access to behavioral health care services by Medicaid
1120recipients, all contracts issued pursuant to this paragraph must
1121require 80 percent of the capitation paid to the managed care
1122plan, including health maintenance organizations and capitated
1123provider service networks, to be expended for the provision of
1124behavioral health care services. If the managed care plan
1125expends less than 80 percent of the capitation paid for the
1126provision of behavioral health care services, the difference
1127shall be returned to the agency. The agency shall provide the
1128plan with a certification letter indicating the amount of
1129capitation paid during each calendar year for behavioral health
1130care services pursuant to this section. The agency may reimburse
1131for substance abuse treatment services on a fee-for-service
1132basis until the agency finds that adequate funds are available
1133for capitated, prepaid arrangements.
1134     1.  By January 1, 2001, The agency shall modify the
1135contracts with the entities providing comprehensive inpatient
1136and outpatient mental health care services to Medicaid
1137recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
1138Counties, to include substance abuse treatment services.
1139     2.  By July 1, 2003, the agency and the Department of
1140Children and Family Services shall execute a written agreement
1141that requires collaboration and joint development of all policy,
1142budgets, procurement documents, contracts, and monitoring plans
1143that have an impact on the state and Medicaid community mental
1144health and targeted case management programs.
1145     2.3.  Except as provided in subparagraph 5. 8., by July 1,
11462006, the agency and the Department of Children and Family
1147Services shall contract with managed care entities in each AHCA
1148area except area 6 or arrange to provide comprehensive inpatient
1149and outpatient mental health and substance abuse services
1150through capitated prepaid arrangements to all Medicaid
1151recipients who are eligible to participate in such plans under
1152federal law and regulation. In AHCA areas where eligible
1153individuals number less than 150,000, the agency shall contract
1154with a single managed care plan to provide comprehensive
1155behavioral health services to all recipients who are not
1156enrolled in a Medicaid health maintenance organization, a
1157provider service network authorized under paragraph (d), or a
1158Medicaid capitated managed care plan authorized under s.
1159409.91211. The agency may contract with more than one
1160comprehensive behavioral health provider to provide care to
1161recipients who are not enrolled in a Medicaid capitated managed
1162care plan authorized under s. 409.91211, a provider service
1163network authorized under paragraph (d), or a Medicaid health
1164maintenance organization in AHCA areas where the eligible
1165population exceeds 150,000. In an AHCA area where the Medicaid
1166managed care pilot program is authorized pursuant to s.
1167409.91211 in one or more counties, the agency may procure a
1168contract with a single entity to serve the remaining counties as
1169an AHCA area or the remaining counties may be included with an
1170adjacent AHCA area and shall be subject to this paragraph.
1171Contracts for comprehensive behavioral health providers awarded
1172pursuant to this section shall be competitively procured. Both
1173for-profit and not-for-profit corporations are eligible to
1174compete. Managed care plans contracting with the agency under
1175subsection (3) or paragraph (d), shall provide and receive
1176payment for the same comprehensive behavioral health benefits as
1177provided in AHCA rules, including handbooks incorporated by
1178reference. In AHCA area 11, the agency shall contract with at
1179least two comprehensive behavioral health care providers to
1180provide behavioral health care to recipients in that area who
1181are enrolled in, or assigned to, the MediPass program. One of
1182the behavioral health care contracts must be with the existing
1183provider service network pilot project, as described in
1184paragraph (d), for the purpose of demonstrating the cost-
1185effectiveness of the provision of quality mental health services
1186through a public hospital-operated managed care model. Payment
1187shall be at an agreed-upon capitated rate to ensure cost
1188savings. Of the recipients in area 11 who are assigned to
1189MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1190MediPass-enrolled recipients shall be assigned to the existing
1191provider service network in area 11 for their behavioral care.
1192     4.  By October 1, 2003, the agency and the department shall
1193submit a plan to the Governor, the President of the Senate, and
1194the Speaker of the House of Representatives which provides for
1195the full implementation of capitated prepaid behavioral health
1196care in all areas of the state.
1197     a.  Implementation shall begin in 2003 in those AHCA areas
1198of the state where the agency is able to establish sufficient
1199capitation rates.
1200     b.  If the agency determines that the proposed capitation
1201rate in any area is insufficient to provide appropriate
1202services, the agency may adjust the capitation rate to ensure
1203that care will be available. The agency and the department may
1204use existing general revenue to address any additional required
1205match but may not over-obligate existing funds on an annualized
1207     c.  Subject to any limitations provided in the General
1208Appropriations Act, the agency, in compliance with appropriate
1209federal authorization, shall develop policies and procedures
1210that allow for certification of local and state funds.
1211     3.5.  Children residing in a statewide inpatient
1212psychiatric program, or in a Department of Juvenile Justice or a
1213Department of Children and Family Services residential program
1214approved as a Medicaid behavioral health overlay services
1215provider may not be included in a behavioral health care prepaid
1216health plan or any other Medicaid managed care plan pursuant to
1217this paragraph.
1218     6.  In converting to a prepaid system of delivery, the
1219agency shall in its procurement document require an entity
1220providing only comprehensive behavioral health care services to
1221prevent the displacement of indigent care patients by enrollees
1222in the Medicaid prepaid health plan providing behavioral health
1223care services from facilities receiving state funding to provide
1224indigent behavioral health care, to facilities licensed under
1225chapter 395 which do not receive state funding for indigent
1226behavioral health care, or reimburse the unsubsidized facility
1227for the cost of behavioral health care provided to the displaced
1228indigent care patient.
1229     4.7.  Traditional community mental health providers under
1230contract with the Department of Children and Family Services
1231pursuant to part IV of chapter 394, child welfare providers
1232under contract with the Department of Children and Family
1233Services in areas 1 and 6, and inpatient mental health providers
1234licensed pursuant to chapter 395 must be offered an opportunity
1235to accept or decline a contract to participate in any provider
1236network for prepaid behavioral health services.
1237     5.8.  All Medicaid-eligible children, except children in
1238area 1 and children in Highlands County, Hardee County, Polk
1239County, or Manatee County of area 6, that are open for child
1240welfare services in the statewide automated child welfare
1241information HomeSafeNet system, shall receive their behavioral
1242health care services through a specialty prepaid plan operated
1243by community-based lead agencies through a single agency or
1244formal agreements among several agencies. The specialty prepaid
1245plan must result in savings to the state comparable to savings
1246achieved in other Medicaid managed care and prepaid programs.
1247Such plan must provide mechanisms to maximize state and local
1248revenues. The specialty prepaid plan shall be developed by the
1249agency and the Department of Children and Family Services. The
1250agency may seek federal waivers to implement this initiative.
1251Medicaid-eligible children whose cases are open for child
1252welfare services in the statewide automated child welfare
1253information HomeSafeNet system and who reside in AHCA area 10
1254shall be enrolled in a capitated provider service network or
1255other capitated managed care plan, which, in coordination with
1256available community-based care providers specified in s.
1257409.1671, shall provide sufficient medical, developmental, and
1258behavioral health services to meet the needs of these children
1259are exempt from the specialty prepaid plan upon the development
1260of a service delivery mechanism for children who reside in area
126110 as specified in s. 409.91211(3)(dd).
1263This paragraph expires October 1, 2014.
1264     (c)  A federally qualified health center or an entity owned
1265by one or more federally qualified health centers or an entity
1266owned by other migrant and community health centers receiving
1267non-Medicaid financial support from the Federal Government to
1268provide health care services on a prepaid or fixed-sum basis to
1269recipients. A federally qualified health center or an entity
1270that is owned by one or more federally qualified health centers
1271and is reimbursed by the agency on a prepaid basis is exempt
1272from parts I and III of chapter 641, but must comply with the
1273solvency requirements in s. 641.2261(2) and meet the appropriate
1274requirements governing financial reserve, quality assurance, and
1275patients' rights established by the agency. This paragraph
1276expires October 1, 2014.
1277     (d)1.  A provider service network, which may be reimbursed
1278on a fee-for-service or prepaid basis. Prepaid provider service
1279networks shall receive per-member, per-month payments. A
1280provider service network that does not choose to be a prepaid
1281plan shall receive fee-for-service rates with a shared savings
1282settlement. The fee-for-service option shall be available to a
1283provider service network only for the first 2 years of the
1284plan's operation or until the contract year beginning September
12851, 2014, whichever is later. The agency shall annually conduct
1286cost reconciliations to determine the amount of cost savings
1287achieved by fee-for-service provider service networks for the
1288dates of service in the period being reconciled. Only payments
1289for covered services for dates of service within the
1290reconciliation period and paid within 6 months after the last
1291date of service in the reconciliation period shall be included.
1292The agency shall perform the necessary adjustments for the
1293inclusion of claims incurred but not reported within the
1294reconciliation for claims that could be received and paid by the
1295agency after the 6-month claims processing time lag. The agency
1296shall provide the results of the reconciliations to the fee-for-
1297service provider service networks within 45 days after the end
1298of the reconciliation period. The fee-for-service provider
1299service networks shall review and provide written comments or a
1300letter of concurrence to the agency within 45 days after receipt
1301of the reconciliation results. This reconciliation shall be
1302considered final.
1303     2.  A provider service network which is reimbursed by the
1304agency on a prepaid basis shall be exempt from parts I and III
1305of chapter 641, but must comply with the solvency requirements
1306in s. 641.2261(2) and meet appropriate financial reserve,
1307quality assurance, and patient rights requirements as
1308established by the agency.
1309     3.  Medicaid recipients assigned to a provider service
1310network shall be chosen equally from those who would otherwise
1311have been assigned to prepaid plans and MediPass. The agency is
1312authorized to seek federal Medicaid waivers as necessary to
1313implement the provisions of this section. This subparagraph
1314expires October 1, 2014. Any contract previously awarded to a
1315provider service network operated by a hospital pursuant to this
1316subsection shall remain in effect for a period of 3 years
1317following the current contract expiration date, regardless of
1318any contractual provisions to the contrary.
1319     4.  A provider service network is a network established or
1320organized and operated by a health care provider, or group of
1321affiliated health care providers, including minority physician
1322networks and emergency room diversion programs that meet the
1323requirements of s. 409.91211, which provides a substantial
1324proportion of the health care items and services under a
1325contract directly through the provider or affiliated group of
1326providers and may make arrangements with physicians or other
1327health care professionals, health care institutions, or any
1328combination of such individuals or institutions to assume all or
1329part of the financial risk on a prospective basis for the
1330provision of basic health services by the physicians, by other
1331health professionals, or through the institutions. The health
1332care providers must have a controlling interest in the governing
1333body of the provider service network organization.
1334     (e)  An entity that provides only comprehensive behavioral
1335health care services to certain Medicaid recipients through an
1336administrative services organization agreement. Such an entity
1337must possess the clinical systems and operational competence to
1338provide comprehensive health care to Medicaid recipients. As
1339used in this paragraph, the term "comprehensive behavioral
1340health care services" means covered mental health and substance
1341abuse treatment services that are available to Medicaid
1342recipients. Any contract awarded under this paragraph must be
1343competitively procured. The agency must ensure that Medicaid
1344recipients have available the choice of at least two managed
1345care plans for their behavioral health care services. This
1346paragraph expires October 1, 2014.
1347     (f)  An entity that provides in-home physician services to
1348test the cost-effectiveness of enhanced home-based medical care
1349to Medicaid recipients with degenerative neurological diseases
1350and other diseases or disabling conditions associated with high
1351costs to Medicaid. The program shall be designed to serve very
1352disabled persons and to reduce Medicaid reimbursed costs for
1353inpatient, outpatient, and emergency department services. The
1354agency shall contract with vendors on a risk-sharing basis.
1355     (g)  Children's provider networks that provide care
1356coordination and care management for Medicaid-eligible pediatric
1357patients, primary care, authorization of specialty care, and
1358other urgent and emergency care through organized providers
1359designed to service Medicaid eligibles under age 18 and
1360pediatric emergency departments' diversion programs. The
1361networks shall provide after-hour operations, including evening
1362and weekend hours, to promote, when appropriate, the use of the
1363children's networks rather than hospital emergency departments.
1364     (f)(h)  An entity authorized in s. 430.205 to contract with
1365the agency and the Department of Elderly Affairs to provide
1366health care and social services on a prepaid or fixed-sum basis
1367to elderly recipients. Such prepaid health care services
1368entities are exempt from the provisions of part I of chapter 641
1369for the first 3 years of operation. An entity recognized under
1370this paragraph that demonstrates to the satisfaction of the
1371Office of Insurance Regulation that it is backed by the full
1372faith and credit of one or more counties in which it operates
1373may be exempted from s. 641.225. This paragraph expires October
13741, 2013.
1375     (g)(i)  A Children's Medical Services Network, as defined
1376in s. 391.021. This paragraph expires October 1, 2014.
1377     (5)  The Agency for Health Care Administration, in
1378partnership with the Department of Elderly Affairs, shall create
1379an integrated, fixed-payment delivery program for Medicaid
1380recipients who are 60 years of age or older or dually eligible
1381for Medicare and Medicaid. The Agency for Health Care
1382Administration shall implement the integrated program initially
1383on a pilot basis in two areas of the state. The pilot areas
1384shall be Area 7 and Area 11 of the Agency for Health Care
1385Administration. Enrollment in the pilot areas shall be on a
1386voluntary basis and in accordance with approved federal waivers
1387and this section. The agency and its program contractors and
1388providers shall not enroll any individual in the integrated
1389program because the individual or the person legally responsible
1390for the individual fails to choose to enroll in the integrated
1391program. Enrollment in the integrated program shall be
1392exclusively by affirmative choice of the eligible individual or
1393by the person legally responsible for the individual. The
1394integrated program must transfer all Medicaid services for
1395eligible elderly individuals who choose to participate into an
1396integrated-care management model designed to serve Medicaid
1397recipients in the community. The integrated program must combine
1398all funding for Medicaid services provided to individuals who
1399are 60 years of age or older or dually eligible for Medicare and
1400Medicaid into the integrated program, including funds for
1401Medicaid home and community-based waiver services; all Medicaid
1402services authorized in ss. 409.905 and 409.906, excluding funds
1403for Medicaid nursing home services unless the agency is able to
1404demonstrate how the integration of the funds will improve
1405coordinated care for these services in a less costly manner; and
1406Medicare coinsurance and deductibles for persons dually eligible
1407for Medicaid and Medicare as prescribed in s. 409.908(13).
1408     (a)  Individuals who are 60 years of age or older or dually
1409eligible for Medicare and Medicaid and enrolled in the
1410developmental disabilities waiver program, the family and
1411supported-living waiver program, the project AIDS care waiver
1412program, the traumatic brain injury and spinal cord injury
1413waiver program, the consumer-directed care waiver program, and
1414the program of all-inclusive care for the elderly program, and
1415residents of institutional care facilities for the
1416developmentally disabled, must be excluded from the integrated
1418     (b)  Managed care entities who meet or exceed the agency's
1419minimum standards are eligible to operate the integrated
1420program. Entities eligible to participate include managed care
1421organizations licensed under chapter 641, including entities
1422eligible to participate in the nursing home diversion program,
1423other qualified providers as defined in s. 430.703(7), community
1424care for the elderly lead agencies, and other state-certified
1425community service networks that meet comparable standards as
1426defined by the agency, in consultation with the Department of
1427Elderly Affairs and the Office of Insurance Regulation, to be
1428financially solvent and able to take on financial risk for
1429managed care. Community service networks that are certified
1430pursuant to the comparable standards defined by the agency are
1431not required to be licensed under chapter 641. Managed care
1432entities who operate the integrated program shall be subject to
1433s. 408.7056. Eligible entities shall choose to serve enrollees
1434who are dually eligible for Medicare and Medicaid, enrollees who
1435are 60 years of age or older, or both.
1436     (c)  The agency must ensure that the capitation-rate-
1437setting methodology for the integrated program is actuarially
1438sound and reflects the intent to provide quality care in the
1439least restrictive setting. The agency must also require
1440integrated-program providers to develop a credentialing system
1441for service providers and to contract with all Gold Seal nursing
1442homes, where feasible, and exclude, where feasible, chronically
1443poor-performing facilities and providers as defined by the
1444agency. The integrated program must develop and maintain an
1445informal provider grievance system that addresses provider
1446payment and contract problems. The agency shall also establish a
1447formal grievance system to address those issues that were not
1448resolved through the informal grievance system. The integrated
1449program must provide that if the recipient resides in a
1450noncontracted residential facility licensed under chapter 400 or
1451chapter 429 at the time of enrollment in the integrated program,
1452the recipient must be permitted to continue to reside in the
1453noncontracted facility as long as the recipient desires. The
1454integrated program must also provide that, in the absence of a
1455contract between the integrated-program provider and the
1456residential facility licensed under chapter 400 or chapter 429,
1457current Medicaid rates must prevail. The integrated-program
1458provider must ensure that electronic nursing home claims that
1459contain sufficient information for processing are paid within 10
1460business days after receipt. Alternately, the integrated-program
1461provider may establish a capitated payment mechanism to
1462prospectively pay nursing homes at the beginning of each month.
1463The agency and the Department of Elderly Affairs must jointly
1464develop procedures to manage the services provided through the
1465integrated program in order to ensure quality and recipient
1467     (d)  The Office of Program Policy Analysis and Government
1468Accountability, in consultation with the Auditor General, shall
1469comprehensively evaluate the pilot project for the integrated,
1470fixed-payment delivery program for Medicaid recipients created
1471under this subsection. The evaluation shall begin as soon as
1472Medicaid recipients are enrolled in the managed care pilot
1473program plans and shall continue for 24 months thereafter. The
1474evaluation must include assessments of each managed care plan in
1475the integrated program with regard to cost savings; consumer
1476education, choice, and access to services; coordination of care;
1477and quality of care. The evaluation must describe administrative
1478or legal barriers to the implementation and operation of the
1479pilot program and include recommendations regarding statewide
1480expansion of the pilot program. The office shall submit its
1481evaluation report to the Governor, the President of the Senate,
1482and the Speaker of the House of Representatives no later than
1483December 31, 2009.
1484     (e)  The agency may seek federal waivers or Medicaid state
1485plan amendments and adopt rules as necessary to administer the
1486integrated program. The agency may implement the approved
1487federal waivers and other provisions as specified in this
1489     (f)  The implementation of the integrated, fixed-payment
1490delivery program created under this subsection is subject to an
1491appropriation in the General Appropriations Act.
1492     (5)(6)  The agency may contract with any public or private
1493entity otherwise authorized by this section on a prepaid or
1494fixed-sum basis for the provision of health care services to
1495recipients. An entity may provide prepaid services to
1496recipients, either directly or through arrangements with other
1497entities, if each entity involved in providing services:
1498     (a)  Is organized primarily for the purpose of providing
1499health care or other services of the type regularly offered to
1500Medicaid recipients;
1501     (b)  Ensures that services meet the standards set by the
1502agency for quality, appropriateness, and timeliness;
1503     (c)  Makes provisions satisfactory to the agency for
1504insolvency protection and ensures that neither enrolled Medicaid
1505recipients nor the agency will be liable for the debts of the
1507     (d)  Submits to the agency, if a private entity, a
1508financial plan that the agency finds to be fiscally sound and
1509that provides for working capital in the form of cash or
1510equivalent liquid assets excluding revenues from Medicaid
1511premium payments equal to at least the first 3 months of
1512operating expenses or $200,000, whichever is greater;
1513     (e)  Furnishes evidence satisfactory to the agency of
1514adequate liability insurance coverage or an adequate plan of
1515self-insurance to respond to claims for injuries arising out of
1516the furnishing of health care;
1517     (f)  Provides, through contract or otherwise, for periodic
1518review of its medical facilities and services, as required by
1519the agency; and
1520     (g)  Provides organizational, operational, financial, and
1521other information required by the agency.
1523This subsection expires October 1, 2014.
1524     (6)(7)  The agency may contract on a prepaid or fixed-sum
1525basis with any health insurer that:
1526     (a)  Pays for health care services provided to enrolled
1527Medicaid recipients in exchange for a premium payment paid by
1528the agency;
1529     (b)  Assumes the underwriting risk; and
1530     (c)  Is organized and licensed under applicable provisions
1531of the Florida Insurance Code and is currently in good standing
1532with the Office of Insurance Regulation.
1534This subsection expires October 1, 2014.
1535     (7)(8)(a)  The agency may contract on a prepaid or fixed-
1536sum basis with an exclusive provider organization to provide
1537health care services to Medicaid recipients provided that the
1538exclusive provider organization meets applicable managed care
1539plan requirements in this section, ss. 409.9122, 409.9123,
1540409.9128, and 627.6472, and other applicable provisions of law.
1541This subsection expires October 1, 2014.
1542     (b)  For a period of no longer than 24 months after the
1543effective date of this paragraph, when a member of an exclusive
1544provider organization that is contracted by the agency to
1545provide health care services to Medicaid recipients in rural
1546areas without a health maintenance organization obtains services
1547from a provider that participates in the Medicaid program in
1548this state, the provider shall be paid in accordance with the
1549appropriate fee schedule for services provided to eligible
1550Medicaid recipients. The agency may seek waiver authority to
1551implement this paragraph.
1552     (8)(9)  The Agency for Health Care Administration may
1553provide cost-effective purchasing of chiropractic services on a
1554fee-for-service basis to Medicaid recipients through
1555arrangements with a statewide chiropractic preferred provider
1556organization incorporated in this state as a not-for-profit
1557corporation. The agency shall ensure that the benefit limits and
1558prior authorization requirements in the current Medicaid program
1559shall apply to the services provided by the chiropractic
1560preferred provider organization. This subsection expires October
15611, 2014.
1562     (9)(10)  The agency shall not contract on a prepaid or
1563fixed-sum basis for Medicaid services with an entity which knows
1564or reasonably should know that any officer, director, agent,
1565managing employee, or owner of stock or beneficial interest in
1566excess of 5 percent common or preferred stock, or the entity
1567itself, has been found guilty of, regardless of adjudication, or
1568entered a plea of nolo contendere, or guilty, to:
1569     (a)  Fraud;
1570     (b)  Violation of federal or state antitrust statutes,
1571including those proscribing price fixing between competitors and
1572the allocation of customers among competitors;
1573     (c)  Commission of a felony involving embezzlement, theft,
1574forgery, income tax evasion, bribery, falsification or
1575destruction of records, making false statements, receiving
1576stolen property, making false claims, or obstruction of justice;
1578     (d)  Any crime in any jurisdiction which directly relates
1579to the provision of health services on a prepaid or fixed-sum
1582This subsection expires October 1, 2014.
1583     (10)(11)  The agency, after notifying the Legislature, may
1584apply for waivers of applicable federal laws and regulations as
1585necessary to implement more appropriate systems of health care
1586for Medicaid recipients and reduce the cost of the Medicaid
1587program to the state and federal governments and shall implement
1588such programs, after legislative approval, within a reasonable
1589period of time after federal approval. These programs must be
1590designed primarily to reduce the need for inpatient care,
1591custodial care and other long-term or institutional care, and
1592other high-cost services. Prior to seeking legislative approval
1593of such a waiver as authorized by this subsection, the agency
1594shall provide notice and an opportunity for public comment.
1595Notice shall be provided to all persons who have made requests
1596of the agency for advance notice and shall be published in the
1597Florida Administrative Weekly not less than 28 days prior to the
1598intended action. This subsection expires October 1, 2016.
1599     (11)(12)  The agency shall establish a postpayment
1600utilization control program designed to identify recipients who
1601may inappropriately overuse or underuse Medicaid services and
1602shall provide methods to correct such misuse. This subsection
1603expires October 1, 2014.
1604     (12)(13)  The agency shall develop and provide coordinated
1605systems of care for Medicaid recipients and may contract with
1606public or private entities to develop and administer such
1607systems of care among public and private health care providers
1608in a given geographic area. This subsection expires October 1,
1610     (13)(14)(a)  The agency shall operate or contract for the
1611operation of utilization management and incentive systems
1612designed to encourage cost-effective use of services and to
1613eliminate services that are medically unnecessary. The agency
1614shall track Medicaid provider prescription and billing patterns
1615and evaluate them against Medicaid medical necessity criteria
1616and coverage and limitation guidelines adopted by rule. Medical
1617necessity determination requires that service be consistent with
1618symptoms or confirmed diagnosis of illness or injury under
1619treatment and not in excess of the patient's needs. The agency
1620shall conduct reviews of provider exceptions to peer group norms
1621and shall, using statistical methodologies, provider profiling,
1622and analysis of billing patterns, detect and investigate
1623abnormal or unusual increases in billing or payment of claims
1624for Medicaid services and medically unnecessary provision of
1625services. Providers that demonstrate a pattern of submitting
1626claims for medically unnecessary services shall be referred to
1627the Medicaid program integrity unit for investigation. In its
1628annual report, required in s. 409.913, the agency shall report
1629on its efforts to control overutilization as described in this
1630subsection paragraph. This subsection expires October 1, 2014.
1631     (b)  The agency shall develop a procedure for determining
1632whether health care providers and service vendors can provide
1633the Medicaid program using a business case that demonstrates
1634whether a particular good or service can offset the cost of
1635providing the good or service in an alternative setting or
1636through other means and therefore should receive a higher
1637reimbursement. The business case must include, but need not be
1638limited to:
1639     1.  A detailed description of the good or service to be
1640provided, a description and analysis of the agency's current
1641performance of the service, and a rationale documenting how
1642providing the service in an alternative setting would be in the
1643best interest of the state, the agency, and its clients.
1644     2.  A cost-benefit analysis documenting the estimated
1645specific direct and indirect costs, savings, performance
1646improvements, risks, and qualitative and quantitative benefits
1647involved in or resulting from providing the service. The cost-
1648benefit analysis must include a detailed plan and timeline
1649identifying all actions that must be implemented to realize
1650expected benefits. The Secretary of Health Care Administration
1651shall verify that all costs, savings, and benefits are valid and
1653     (c)  If the agency determines that the increased
1654reimbursement is cost-effective, the agency shall recommend a
1655change in the reimbursement schedule for that particular good or
1656service. If, within 12 months after implementing any rate change
1657under this procedure, the agency determines that costs were not
1658offset by the increased reimbursement schedule, the agency may
1659revert to the former reimbursement schedule for the particular
1660good or service.
1661     (14)(15)(a)  The agency shall operate the Comprehensive
1662Assessment and Review for Long-Term Care Services (CARES)
1663nursing facility preadmission screening program to ensure that
1664Medicaid payment for nursing facility care is made only for
1665individuals whose conditions require such care and to ensure
1666that long-term care services are provided in the setting most
1667appropriate to the needs of the person and in the most
1668economical manner possible. The CARES program shall also ensure
1669that individuals participating in Medicaid home and community-
1670based waiver programs meet criteria for those programs,
1671consistent with approved federal waivers.
1672     (b)  The agency shall operate the CARES program through an
1673interagency agreement with the Department of Elderly Affairs.
1674The agency, in consultation with the Department of Elderly
1675Affairs, may contract for any function or activity of the CARES
1676program, including any function or activity required by 42
1677C.F.R. part 483.20, relating to preadmission screening and
1678resident review.
1679     (c)  Prior to making payment for nursing facility services
1680for a Medicaid recipient, the agency must verify that the
1681nursing facility preadmission screening program has determined
1682that the individual requires nursing facility care and that the
1683individual cannot be safely served in community-based programs.
1684The nursing facility preadmission screening program shall refer
1685a Medicaid recipient to a community-based program if the
1686individual could be safely served at a lower cost and the
1687recipient chooses to participate in such program. For
1688individuals whose nursing home stay is initially funded by
1689Medicare and Medicare coverage is being terminated for lack of
1690progress towards rehabilitation, CARES staff shall consult with
1691the person making the determination of progress toward
1692rehabilitation to ensure that the recipient is not being
1693inappropriately disqualified from Medicare coverage. If, in
1694their professional judgment, CARES staff believes that a
1695Medicare beneficiary is still making progress toward
1696rehabilitation, they may assist the Medicare beneficiary with an
1697appeal of the disqualification from Medicare coverage. The use
1698of CARES teams to review Medicare denials for coverage under
1699this section is authorized only if it is determined that such
1700reviews qualify for federal matching funds through Medicaid. The
1701agency shall seek or amend federal waivers as necessary to
1702implement this section.
1703     (d)  For the purpose of initiating immediate prescreening
1704and diversion assistance for individuals residing in nursing
1705homes and in order to make families aware of alternative long-
1706term care resources so that they may choose a more cost-
1707effective setting for long-term placement, CARES staff shall
1708conduct an assessment and review of a sample of individuals
1709whose nursing home stay is expected to exceed 20 days,
1710regardless of the initial funding source for the nursing home
1711placement. CARES staff shall provide counseling and referral
1712services to these individuals regarding choosing appropriate
1713long-term care alternatives. This paragraph does not apply to
1714continuing care facilities licensed under chapter 651 or to
1715retirement communities that provide a combination of nursing
1716home, independent living, and other long-term care services.
1717     (e)  By January 15 of each year, the agency shall submit a
1718report to the Legislature describing the operations of the CARES
1719program. The report must describe:
1720     1.  Rate of diversion to community alternative programs;
1721     2.  CARES program staffing needs to achieve additional
1723     3.  Reasons the program is unable to place individuals in
1724less restrictive settings when such individuals desired such
1725services and could have been served in such settings;
1726     4.  Barriers to appropriate placement, including barriers
1727due to policies or operations of other agencies or state-funded
1728programs; and
1729     5.  Statutory changes necessary to ensure that individuals
1730in need of long-term care services receive care in the least
1731restrictive environment.
1732     (f)  The Department of Elderly Affairs shall track
1733individuals over time who are assessed under the CARES program
1734and who are diverted from nursing home placement. By January 15
1735of each year, the department shall submit to the Legislature a
1736longitudinal study of the individuals who are diverted from
1737nursing home placement. The study must include:
1738     1.  The demographic characteristics of the individuals
1739assessed and diverted from nursing home placement, including,
1740but not limited to, age, race, gender, frailty, caregiver
1741status, living arrangements, and geographic location;
1742     2.  A summary of community services provided to individuals
1743for 1 year after assessment and diversion;
1744     3.  A summary of inpatient hospital admissions for
1745individuals who have been diverted; and
1746     4.  A summary of the length of time between diversion and
1747subsequent entry into a nursing home or death.
1749This subsection expires October 1, 2013.
1750     (15)(16)(a)  The agency shall identify health care
1751utilization and price patterns within the Medicaid program which
1752are not cost-effective or medically appropriate and assess the
1753effectiveness of new or alternate methods of providing and
1754monitoring service, and may implement such methods as it
1755considers appropriate. Such methods may include disease
1756management initiatives, an integrated and systematic approach
1757for managing the health care needs of recipients who are at risk
1758of or diagnosed with a specific disease by using best practices,
1759prevention strategies, clinical-practice improvement, clinical
1760interventions and protocols, outcomes research, information
1761technology, and other tools and resources to reduce overall
1762costs and improve measurable outcomes.
1763     (b)  The responsibility of the agency under this subsection
1764shall include the development of capabilities to identify actual
1765and optimal practice patterns; patient and provider educational
1766initiatives; methods for determining patient compliance with
1767prescribed treatments; fraud, waste, and abuse prevention and
1768detection programs; and beneficiary case management programs.
1769     1.  The practice pattern identification program shall
1770evaluate practitioner prescribing patterns based on national and
1771regional practice guidelines, comparing practitioners to their
1772peer groups. The agency and its Drug Utilization Review Board
1773shall consult with the Department of Health and a panel of
1774practicing health care professionals consisting of the
1775following: the Speaker of the House of Representatives and the
1776President of the Senate shall each appoint three physicians
1777licensed under chapter 458 or chapter 459; and the Governor
1778shall appoint two pharmacists licensed under chapter 465 and one
1779dentist licensed under chapter 466 who is an oral surgeon. Terms
1780of the panel members shall expire at the discretion of the
1781appointing official. The advisory panel shall be responsible for
1782evaluating treatment guidelines and recommending ways to
1783incorporate their use in the practice pattern identification
1784program. Practitioners who are prescribing inappropriately or
1785inefficiently, as determined by the agency, may have their
1786prescribing of certain drugs subject to prior authorization or
1787may be terminated from all participation in the Medicaid
1789     2.  The agency shall also develop educational interventions
1790designed to promote the proper use of medications by providers
1791and beneficiaries.
1792     3.  The agency shall implement a pharmacy fraud, waste, and
1793abuse initiative that may include a surety bond or letter of
1794credit requirement for participating pharmacies, enhanced
1795provider auditing practices, the use of additional fraud and
1796abuse software, recipient management programs for beneficiaries
1797inappropriately using their benefits, and other steps that will
1798eliminate provider and recipient fraud, waste, and abuse. The
1799initiative shall address enforcement efforts to reduce the
1800number and use of counterfeit prescriptions.
1801     4.  By September 30, 2002, the agency shall contract with
1802an entity in the state to implement a wireless handheld clinical
1803pharmacology drug information database for practitioners. The
1804initiative shall be designed to enhance the agency's efforts to
1805reduce fraud, abuse, and errors in the prescription drug benefit
1806program and to otherwise further the intent of this paragraph.
1807     5.  By April 1, 2006, the agency shall contract with an
1808entity to design a database of clinical utilization information
1809or electronic medical records for Medicaid providers. This
1810system must be web-based and allow providers to review on a
1811real-time basis the utilization of Medicaid services, including,
1812but not limited to, physician office visits, inpatient and
1813outpatient hospitalizations, laboratory and pathology services,
1814radiological and other imaging services, dental care, and
1815patterns of dispensing prescription drugs in order to coordinate
1816care and identify potential fraud and abuse.
1817     6.  The agency may apply for any federal waivers needed to
1818administer this paragraph.
1820This subsection expires October 1, 2014.
1821     (16)(17)  An entity contracting on a prepaid or fixed-sum
1822basis shall meet the surplus requirements of s. 641.225. If an
1823entity's surplus falls below an amount equal to the surplus
1824requirements of s. 641.225, the agency shall prohibit the entity
1825from engaging in marketing and preenrollment activities, shall
1826cease to process new enrollments, and may not renew the entity's
1827contract until the required balance is achieved. The
1828requirements of this subsection do not apply:
1829     (a)  Where a public entity agrees to fund any deficit
1830incurred by the contracting entity; or
1831     (b)  Where the entity's performance and obligations are
1832guaranteed in writing by a guaranteeing organization which:
1833     1.  Has been in operation for at least 5 years and has
1834assets in excess of $50 million; or
1835     2.  Submits a written guarantee acceptable to the agency
1836which is irrevocable during the term of the contracting entity's
1837contract with the agency and, upon termination of the contract,
1838until the agency receives proof of satisfaction of all
1839outstanding obligations incurred under the contract.
1841This subsection expires October 1, 2014.
1842     (17)(18)(a)  The agency may require an entity contracting
1843on a prepaid or fixed-sum basis to establish a restricted
1844insolvency protection account with a federally guaranteed
1845financial institution licensed to do business in this state. The
1846entity shall deposit into that account 5 percent of the
1847capitation payments made by the agency each month until a
1848maximum total of 2 percent of the total current contract amount
1849is reached. The restricted insolvency protection account may be
1850drawn upon with the authorized signatures of two persons
1851designated by the entity and two representatives of the agency.
1852If the agency finds that the entity is insolvent, the agency may
1853draw upon the account solely with the two authorized signatures
1854of representatives of the agency, and the funds may be disbursed
1855to meet financial obligations incurred by the entity under the
1856prepaid contract. If the contract is terminated, expired, or not
1857continued, the account balance must be released by the agency to
1858the entity upon receipt of proof of satisfaction of all
1859outstanding obligations incurred under this contract.
1860     (b)  The agency may waive the insolvency protection account
1861requirement in writing when evidence is on file with the agency
1862of adequate insolvency insurance and reinsurance that will
1863protect enrollees if the entity becomes unable to meet its
1865     (18)(19)  An entity that contracts with the agency on a
1866prepaid or fixed-sum basis for the provision of Medicaid
1867services shall reimburse any hospital or physician that is
1868outside the entity's authorized geographic service area as
1869specified in its contract with the agency, and that provides
1870services authorized by the entity to its members, at a rate
1871negotiated with the hospital or physician for the provision of
1872services or according to the lesser of the following:
1873     (a)  The usual and customary charges made to the general
1874public by the hospital or physician; or
1875     (b)  The Florida Medicaid reimbursement rate established
1876for the hospital or physician.
1878This subsection expires October 1, 2014.
1879     (19)(20)  When a merger or acquisition of a Medicaid
1880prepaid contractor has been approved by the Office of Insurance
1881Regulation pursuant to s. 628.4615, the agency shall approve the
1882assignment or transfer of the appropriate Medicaid prepaid
1883contract upon request of the surviving entity of the merger or
1884acquisition if the contractor and the other entity have been in
1885good standing with the agency for the most recent 12-month
1886period, unless the agency determines that the assignment or
1887transfer would be detrimental to the Medicaid recipients or the
1888Medicaid program. To be in good standing, an entity must not
1889have failed accreditation or committed any material violation of
1890the requirements of s. 641.52 and must meet the Medicaid
1891contract requirements. For purposes of this section, a merger or
1892acquisition means a change in controlling interest of an entity,
1893including an asset or stock purchase. This subsection expires
1894October 1, 2014.
1895     (20)(21)  Any entity contracting with the agency pursuant
1896to this section to provide health care services to Medicaid
1897recipients is prohibited from engaging in any of the following
1898practices or activities:
1899     (a)  Practices that are discriminatory, including, but not
1900limited to, attempts to discourage participation on the basis of
1901actual or perceived health status.
1902     (b)  Activities that could mislead or confuse recipients,
1903or misrepresent the organization, its marketing representatives,
1904or the agency. Violations of this paragraph include, but are not
1905limited to:
1906     1.  False or misleading claims that marketing
1907representatives are employees or representatives of the state or
1908county, or of anyone other than the entity or the organization
1909by whom they are reimbursed.
1910     2.  False or misleading claims that the entity is
1911recommended or endorsed by any state or county agency, or by any
1912other organization which has not certified its endorsement in
1913writing to the entity.
1914     3.  False or misleading claims that the state or county
1915recommends that a Medicaid recipient enroll with an entity.
1916     4.  Claims that a Medicaid recipient will lose benefits
1917under the Medicaid program, or any other health or welfare
1918benefits to which the recipient is legally entitled, if the
1919recipient does not enroll with the entity.
1920     (c)  Granting or offering of any monetary or other valuable
1921consideration for enrollment, except as authorized by subsection
1922(23) (24).
1923     (d)  Door-to-door solicitation of recipients who have not
1924contacted the entity or who have not invited the entity to make
1925a presentation.
1926     (e)  Solicitation of Medicaid recipients by marketing
1927representatives stationed in state offices unless approved and
1928supervised by the agency or its agent and approved by the
1929affected state agency when solicitation occurs in an office of
1930the state agency. The agency shall ensure that marketing
1931representatives stationed in state offices shall market their
1932managed care plans to Medicaid recipients only in designated
1933areas and in such a way as to not interfere with the recipients'
1934activities in the state office.
1935     (f)  Enrollment of Medicaid recipients.
1936     (21)(22)  The agency may impose a fine for a violation of
1937this section or the contract with the agency by a person or
1938entity that is under contract with the agency. With respect to
1939any nonwillful violation, such fine shall not exceed $2,500 per
1940violation. In no event shall such fine exceed an aggregate
1941amount of $10,000 for all nonwillful violations arising out of
1942the same action. With respect to any knowing and willful
1943violation of this section or the contract with the agency, the
1944agency may impose a fine upon the entity in an amount not to
1945exceed $20,000 for each such violation. In no event shall such
1946fine exceed an aggregate amount of $100,000 for all knowing and
1947willful violations arising out of the same action. This
1948subsection expires October 1, 2014.
1949     (22)(23)  A health maintenance organization or a person or
1950entity exempt from chapter 641 that is under contract with the
1951agency for the provision of health care services to Medicaid
1952recipients may not use or distribute marketing materials used to
1953solicit Medicaid recipients, unless such materials have been
1954approved by the agency. The provisions of this subsection do not
1955apply to general advertising and marketing materials used by a
1956health maintenance organization to solicit both non-Medicaid
1957subscribers and Medicaid recipients. This subsection expires
1958October 1, 2014.
1959     (23)(24)  Upon approval by the agency, health maintenance
1960organizations and persons or entities exempt from chapter 641
1961that are under contract with the agency for the provision of
1962health care services to Medicaid recipients may be permitted
1963within the capitation rate to provide additional health benefits
1964that the agency has found are of high quality, are practicably
1965available, provide reasonable value to the recipient, and are
1966provided at no additional cost to the state. This subsection
1967expires October 1, 2014.
1968     (24)(25)  The agency shall utilize the statewide health
1969maintenance organization complaint hotline for the purpose of
1970investigating and resolving Medicaid and prepaid health plan
1971complaints, maintaining a record of complaints and confirmed
1972problems, and receiving disenrollment requests made by
1973recipients. This subsection expires October 1, 2014.
1974     (25)(26)  The agency shall require the publication of the
1975health maintenance organization's and the prepaid health plan's
1976consumer services telephone numbers and the "800" telephone
1977number of the statewide health maintenance organization
1978complaint hotline on each Medicaid identification card issued by
1979a health maintenance organization or prepaid health plan
1980contracting with the agency to serve Medicaid recipients and on
1981each subscriber handbook issued to a Medicaid recipient. This
1982subsection expires October 1, 2014.
1983     (26)(27)  The agency shall establish a health care quality
1984improvement system for those entities contracting with the
1985agency pursuant to this section, incorporating all the standards
1986and guidelines developed by the Medicaid Bureau of the Health
1987Care Financing Administration as a part of the quality assurance
1988reform initiative. The system shall include, but need not be
1989limited to, the following:
1990     (a)  Guidelines for internal quality assurance programs,
1991including standards for:
1992     1.  Written quality assurance program descriptions.
1993     2.  Responsibilities of the governing body for monitoring,
1994evaluating, and making improvements to care.
1995     3.  An active quality assurance committee.
1996     4.  Quality assurance program supervision.
1997     5.  Requiring the program to have adequate resources to
1998effectively carry out its specified activities.
1999     6.  Provider participation in the quality assurance
2001     7.  Delegation of quality assurance program activities.
2002     8.  Credentialing and recredentialing.
2003     9.  Enrollee rights and responsibilities.
2004     10.  Availability and accessibility to services and care.
2005     11.  Ambulatory care facilities.
2006     12.  Accessibility and availability of medical records, as
2007well as proper recordkeeping and process for record review.
2008     13.  Utilization review.
2009     14.  A continuity of care system.
2010     15.  Quality assurance program documentation.
2011     16.  Coordination of quality assurance activity with other
2012management activity.
2013     17.  Delivering care to pregnant women and infants; to
2014elderly and disabled recipients, especially those who are at
2015risk of institutional placement; to persons with developmental
2016disabilities; and to adults who have chronic, high-cost medical
2018     (b)  Guidelines which require the entities to conduct
2019quality-of-care studies which:
2020     1.  Target specific conditions and specific health service
2021delivery issues for focused monitoring and evaluation.
2022     2.  Use clinical care standards or practice guidelines to
2023objectively evaluate the care the entity delivers or fails to
2024deliver for the targeted clinical conditions and health services
2025delivery issues.
2026     3.  Use quality indicators derived from the clinical care
2027standards or practice guidelines to screen and monitor care and
2028services delivered.
2029     (c)  Guidelines for external quality review of each
2030contractor which require: focused studies of patterns of care;
2031individual care review in specific situations; and followup
2032activities on previous pattern-of-care study findings and
2033individual-care-review findings. In designing the external
2034quality review function and determining how it is to operate as
2035part of the state's overall quality improvement system, the
2036agency shall construct its external quality review organization
2037and entity contracts to address each of the following:
2038     1.  Delineating the role of the external quality review
2040     2.  Length of the external quality review organization
2041contract with the state.
2042     3.  Participation of the contracting entities in designing
2043external quality review organization review activities.
2044     4.  Potential variation in the type of clinical conditions
2045and health services delivery issues to be studied at each plan.
2046     5.  Determining the number of focused pattern-of-care
2047studies to be conducted for each plan.
2048     6.  Methods for implementing focused studies.
2049     7.  Individual care review.
2050     8.  Followup activities.
2052This subsection expires October 1, 2016.
2053     (27)(28)  In order to ensure that children receive health
2054care services for which an entity has already been compensated,
2055an entity contracting with the agency pursuant to this section
2056shall achieve an annual Early and Periodic Screening, Diagnosis,
2057and Treatment (EPSDT) Service screening rate of at least 60
2058percent for those recipients continuously enrolled for at least
20598 months. The agency shall develop a method by which the EPSDT
2060screening rate shall be calculated. For any entity which does
2061not achieve the annual 60 percent rate, the entity must submit a
2062corrective action plan for the agency's approval. If the entity
2063does not meet the standard established in the corrective action
2064plan during the specified timeframe, the agency is authorized to
2065impose appropriate contract sanctions. At least annually, the
2066agency shall publicly release the EPSDT Services screening rates
2067of each entity it has contracted with on a prepaid basis to
2068serve Medicaid recipients. This subsection expires October 1,
2070     (28)(29)  The agency shall perform enrollments and
2071disenrollments for Medicaid recipients who are eligible for
2072MediPass or managed care plans. Notwithstanding the prohibition
2073contained in paragraph (20)(21)(f), managed care plans may
2074perform preenrollments of Medicaid recipients under the
2075supervision of the agency or its agents. For the purposes of
2076this section, the term "preenrollment" means the provision of
2077marketing and educational materials to a Medicaid recipient and
2078assistance in completing the application forms, but does not
2079include actual enrollment into a managed care plan. An
2080application for enrollment may not be deemed complete until the
2081agency or its agent verifies that the recipient made an
2082informed, voluntary choice. The agency, in cooperation with the
2083Department of Children and Family Services, may test new
2084marketing initiatives to inform Medicaid recipients about their
2085managed care options at selected sites. The agency may contract
2086with a third party to perform managed care plan and MediPass
2087enrollment and disenrollment services for Medicaid recipients
2088and may adopt rules to administer such services. The agency may
2089adjust the capitation rate only to cover the costs of a third-
2090party enrollment and disenrollment contract, and for agency
2091supervision and management of the managed care plan enrollment
2092and disenrollment contract. This subsection expires October 1,
2094     (29)(30)  Any lists of providers made available to Medicaid
2095recipients, MediPass enrollees, or managed care plan enrollees
2096shall be arranged alphabetically showing the provider's name and
2097specialty and, separately, by specialty in alphabetical order.
2098This subsection expires October 1, 2014.
2099     (30)(31)  The agency shall establish an enhanced managed
2100care quality assurance oversight function, to include at least
2101the following components:
2102     (a)  At least quarterly analysis and followup, including
2103sanctions as appropriate, of managed care participant
2104utilization of services.
2105     (b)  At least quarterly analysis and followup, including
2106sanctions as appropriate, of quality findings of the Medicaid
2107peer review organization and other external quality assurance
2109     (c)  At least quarterly analysis and followup, including
2110sanctions as appropriate, of the fiscal viability of managed
2111care plans.
2112     (d)  At least quarterly analysis and followup, including
2113sanctions as appropriate, of managed care participant
2114satisfaction and disenrollment surveys.
2115     (e)  The agency shall conduct regular and ongoing Medicaid
2116recipient satisfaction surveys.
2118The analyses and followup activities conducted by the agency
2119under its enhanced managed care quality assurance oversight
2120function shall not duplicate the activities of accreditation
2121reviewers for entities regulated under part III of chapter 641,
2122but may include a review of the finding of such reviewers. This
2123subsection expires October 1, 2014.
2124     (31)(32)  Each managed care plan that is under contract
2125with the agency to provide health care services to Medicaid
2126recipients shall annually conduct a background check with the
2127Department of Law Enforcement of all persons with ownership
2128interest of 5 percent or more or executive management
2129responsibility for the managed care plan and shall submit to the
2130agency information concerning any such person who has been found
2131guilty of, regardless of adjudication, or has entered a plea of
2132nolo contendere or guilty to, any of the offenses listed in s.
2133435.04. This subsection expires October 1, 2014.
2134     (32)(33)  The agency shall, by rule, develop a process
2135whereby a Medicaid managed care plan enrollee who wishes to
2136enter hospice care may be disenrolled from the managed care plan
2137within 24 hours after contacting the agency regarding such
2138request. The agency rule shall include a methodology for the
2139agency to recoup managed care plan payments on a pro rata basis
2140if payment has been made for the enrollment month when
2141disenrollment occurs. This subsection expires October 1, 2014.
2142     (33)(34)  The agency and entities that contract with the
2143agency to provide health care services to Medicaid recipients
2144under this section or ss. 409.91211 and 409.9122 must comply
2145with the provisions of s. 641.513 in providing emergency
2146services and care to Medicaid recipients and MediPass
2147recipients. Where feasible, safe, and cost-effective, the agency
2148shall encourage hospitals, emergency medical services providers,
2149and other public and private health care providers to work
2150together in their local communities to enter into agreements or
2151arrangements to ensure access to alternatives to emergency
2152services and care for those Medicaid recipients who need
2153nonemergent care. The agency shall coordinate with hospitals,
2154emergency medical services providers, private health plans,
2155capitated managed care networks as established in s. 409.91211,
2156and other public and private health care providers to implement
2157the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
2158and 641.31097 to develop and implement emergency department
2159diversion programs for Medicaid recipients. This subsection
2160expires October 1, 2014.
2161     (34)(35)  All entities providing health care services to
2162Medicaid recipients shall make available, and encourage all
2163pregnant women and mothers with infants to receive, and provide
2164documentation in the medical records to reflect, the following:
2165     (a)  Healthy Start prenatal or infant screening.
2166     (b)  Healthy Start care coordination, when screening or
2167other factors indicate need.
2168     (c)  Healthy Start enhanced services in accordance with the
2169prenatal or infant screening results.
2170     (d)  Immunizations in accordance with recommendations of
2171the Advisory Committee on Immunization Practices of the United
2172States Public Health Service and the American Academy of
2173Pediatrics, as appropriate.
2174     (e)  Counseling and services for family planning to all
2175women and their partners.
2176     (f)  A scheduled postpartum visit for the purpose of
2177voluntary family planning, to include discussion of all methods
2178of contraception, as appropriate.
2179     (g)  Referral to the Special Supplemental Nutrition Program
2180for Women, Infants, and Children (WIC).
2182This subsection expires October 1, 2014.
2183     (35)(36)  Any entity that provides Medicaid prepaid health
2184plan services shall ensure the appropriate coordination of
2185health care services with an assisted living facility in cases
2186where a Medicaid recipient is both a member of the entity's
2187prepaid health plan and a resident of the assisted living
2188facility. If the entity is at risk for Medicaid targeted case
2189management and behavioral health services, the entity shall
2190inform the assisted living facility of the procedures to follow
2191should an emergent condition arise. This subsection expires
2192October 1, 2014.
2193     (37)  The agency may seek and implement federal waivers
2194necessary to provide for cost-effective purchasing of home
2195health services, private duty nursing services, transportation,
2196independent laboratory services, and durable medical equipment
2197and supplies through competitive bidding pursuant to s. 287.057.
2198The agency may request appropriate waivers from the federal
2199Health Care Financing Administration in order to competitively
2200bid such services. The agency may exclude providers not selected
2201through the bidding process from the Medicaid provider network.
2202     (36)(38)  The agency shall enter into agreements with not-
2203for-profit organizations based in this state for the purpose of
2204providing vision screening. This subsection expires October 1,
2206     (37)(39)(a)  The agency shall implement a Medicaid
2207prescribed-drug spending-control program that includes the
2208following components:
2209     1.  A Medicaid preferred drug list, which shall be a
2210listing of cost-effective therapeutic options recommended by the
2211Medicaid Pharmacy and Therapeutics Committee established
2212pursuant to s. 409.91195 and adopted by the agency for each
2213therapeutic class on the preferred drug list. At the discretion
2214of the committee, and when feasible, the preferred drug list
2215should include at least two products in a therapeutic class. The
2216agency may post the preferred drug list and updates to the
2217preferred drug list on an Internet website without following the
2218rulemaking procedures of chapter 120. Antiretroviral agents are
2219excluded from the preferred drug list. The agency shall also
2220limit the amount of a prescribed drug dispensed to no more than
2221a 34-day supply unless the drug products' smallest marketed
2222package is greater than a 34-day supply, or the drug is
2223determined by the agency to be a maintenance drug in which case
2224a 100-day maximum supply may be authorized. The agency is
2225authorized to seek any federal waivers necessary to implement
2226these cost-control programs and to continue participation in the
2227federal Medicaid rebate program, or alternatively to negotiate
2228state-only manufacturer rebates. The agency may adopt rules to
2229implement this subparagraph. The agency shall continue to
2230provide unlimited contraceptive drugs and items. The agency must
2231establish procedures to ensure that:
2232     a.  There is a response to a request for prior consultation
2233by telephone or other telecommunication device within 24 hours
2234after receipt of a request for prior consultation; and
2235     b.  A 72-hour supply of the drug prescribed is provided in
2236an emergency or when the agency does not provide a response
2237within 24 hours as required by sub-subparagraph a.
2238     2.  Reimbursement to pharmacies for Medicaid prescribed
2239drugs shall be set at the lesser of: the average wholesale price
2240(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2241plus 4.75 percent, the federal upper limit (FUL), the state
2242maximum allowable cost (SMAC), or the usual and customary (UAC)
2243charge billed by the provider.
2244     3.  The agency shall develop and implement a process for
2245managing the drug therapies of Medicaid recipients who are using
2246significant numbers of prescribed drugs each month. The
2247management process may include, but is not limited to,
2248comprehensive, physician-directed medical-record reviews, claims
2249analyses, and case evaluations to determine the medical
2250necessity and appropriateness of a patient's treatment plan and
2251drug therapies. The agency may contract with a private
2252organization to provide drug-program-management services. The
2253Medicaid drug benefit management program shall include
2254initiatives to manage drug therapies for HIV/AIDS patients,
2255patients using 20 or more unique prescriptions in a 180-day
2256period, and the top 1,000 patients in annual spending. The
2257agency shall enroll any Medicaid recipient in the drug benefit
2258management program if he or she meets the specifications of this
2259provision and is not enrolled in a Medicaid health maintenance
2261     4.  The agency may limit the size of its pharmacy network
2262based on need, competitive bidding, price negotiations,
2263credentialing, or similar criteria. The agency shall give
2264special consideration to rural areas in determining the size and
2265location of pharmacies included in the Medicaid pharmacy
2266network. A pharmacy credentialing process may include criteria
2267such as a pharmacy's full-service status, location, size,
2268patient educational programs, patient consultation, disease
2269management services, and other characteristics. The agency may
2270impose a moratorium on Medicaid pharmacy enrollment when it is
2271determined that it has a sufficient number of Medicaid-
2272participating providers. The agency must allow dispensing
2273practitioners to participate as a part of the Medicaid pharmacy
2274network regardless of the practitioner's proximity to any other
2275entity that is dispensing prescription drugs under the Medicaid
2276program. A dispensing practitioner must meet all credentialing
2277requirements applicable to his or her practice, as determined by
2278the agency.
2279     5.  The agency shall develop and implement a program that
2280requires Medicaid practitioners who prescribe drugs to use a
2281counterfeit-proof prescription pad for Medicaid prescriptions.
2282The agency shall require the use of standardized counterfeit-
2283proof prescription pads by Medicaid-participating prescribers or
2284prescribers who write prescriptions for Medicaid recipients. The
2285agency may implement the program in targeted geographic areas or
2287     6.  The agency may enter into arrangements that require
2288manufacturers of generic drugs prescribed to Medicaid recipients
2289to provide rebates of at least 15.1 percent of the average
2290manufacturer price for the manufacturer's generic products.
2291These arrangements shall require that if a generic-drug
2292manufacturer pays federal rebates for Medicaid-reimbursed drugs
2293at a level below 15.1 percent, the manufacturer must provide a
2294supplemental rebate to the state in an amount necessary to
2295achieve a 15.1-percent rebate level.
2296     7.  The agency may establish a preferred drug list as
2297described in this subsection, and, pursuant to the establishment
2298of such preferred drug list, it is authorized to negotiate
2299supplemental rebates from manufacturers that are in addition to
2300those required by Title XIX of the Social Security Act and at no
2301less than 14 percent of the average manufacturer price as
2302defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2303the federal or supplemental rebate, or both, equals or exceeds
230429 percent. There is no upper limit on the supplemental rebates
2305the agency may negotiate. The agency may determine that specific
2306products, brand-name or generic, are competitive at lower rebate
2307percentages. Agreement to pay the minimum supplemental rebate
2308percentage will guarantee a manufacturer that the Medicaid
2309Pharmaceutical and Therapeutics Committee will consider a
2310product for inclusion on the preferred drug list. However, a
2311pharmaceutical manufacturer is not guaranteed placement on the
2312preferred drug list by simply paying the minimum supplemental
2313rebate. Agency decisions will be made on the clinical efficacy
2314of a drug and recommendations of the Medicaid Pharmaceutical and
2315Therapeutics Committee, as well as the price of competing
2316products minus federal and state rebates. The agency is
2317authorized to contract with an outside agency or contractor to
2318conduct negotiations for supplemental rebates. For the purposes
2319of this section, the term "supplemental rebates" means cash
2320rebates. Effective July 1, 2004, value-added programs as a
2321substitution for supplemental rebates are prohibited. The agency
2322is authorized to seek any federal waivers to implement this
2324     8.  The Agency for Health Care Administration shall expand
2325home delivery of pharmacy products. To assist Medicaid patients
2326in securing their prescriptions and reduce program costs, the
2327agency shall expand its current mail-order-pharmacy diabetes-
2328supply program to include all generic and brand-name drugs used
2329by Medicaid patients with diabetes. Medicaid recipients in the
2330current program may obtain nondiabetes drugs on a voluntary
2331basis. This initiative is limited to the geographic area covered
2332by the current contract. The agency may seek and implement any
2333federal waivers necessary to implement this subparagraph.
2334     9.  The agency shall limit to one dose per month any drug
2335prescribed to treat erectile dysfunction.
2336     10.a.  The agency may implement a Medicaid behavioral drug
2337management system. The agency may contract with a vendor that
2338has experience in operating behavioral drug management systems
2339to implement this program. The agency is authorized to seek
2340federal waivers to implement this program.
2341     b.  The agency, in conjunction with the Department of
2342Children and Family Services, may implement the Medicaid
2343behavioral drug management system that is designed to improve
2344the quality of care and behavioral health prescribing practices
2345based on best practice guidelines, improve patient adherence to
2346medication plans, reduce clinical risk, and lower prescribed
2347drug costs and the rate of inappropriate spending on Medicaid
2348behavioral drugs. The program may include the following
2350     (I)  Provide for the development and adoption of best
2351practice guidelines for behavioral health-related drugs such as
2352antipsychotics, antidepressants, and medications for treating
2353bipolar disorders and other behavioral conditions; translate
2354them into practice; review behavioral health prescribers and
2355compare their prescribing patterns to a number of indicators
2356that are based on national standards; and determine deviations
2357from best practice guidelines.
2358     (II)  Implement processes for providing feedback to and
2359educating prescribers using best practice educational materials
2360and peer-to-peer consultation.
2361     (III)  Assess Medicaid beneficiaries who are outliers in
2362their use of behavioral health drugs with regard to the numbers
2363and types of drugs taken, drug dosages, combination drug
2364therapies, and other indicators of improper use of behavioral
2365health drugs.
2366     (IV)  Alert prescribers to patients who fail to refill
2367prescriptions in a timely fashion, are prescribed multiple same-
2368class behavioral health drugs, and may have other potential
2369medication problems.
2370     (V)  Track spending trends for behavioral health drugs and
2371deviation from best practice guidelines.
2372     (VI)  Use educational and technological approaches to
2373promote best practices, educate consumers, and train prescribers
2374in the use of practice guidelines.
2375     (VII)  Disseminate electronic and published materials.
2376     (VIII)  Hold statewide and regional conferences.
2377     (IX)  Implement a disease management program with a model
2378quality-based medication component for severely mentally ill
2379individuals and emotionally disturbed children who are high
2380users of care.
2381     11.a.  The agency shall implement a Medicaid prescription
2382drug management system. The agency may contract with a vendor
2383that has experience in operating prescription drug management
2384systems in order to implement this system. Any management system
2385that is implemented in accordance with this subparagraph must
2386rely on cooperation between physicians and pharmacists to
2387determine appropriate practice patterns and clinical guidelines
2388to improve the prescribing, dispensing, and use of drugs in the
2389Medicaid program. The agency may seek federal waivers to
2390implement this program.
2391     b.  The drug management system must be designed to improve
2392the quality of care and prescribing practices based on best
2393practice guidelines, improve patient adherence to medication
2394plans, reduce clinical risk, and lower prescribed drug costs and
2395the rate of inappropriate spending on Medicaid prescription
2396drugs. The program must:
2397     (I)  Provide for the development and adoption of best
2398practice guidelines for the prescribing and use of drugs in the
2399Medicaid program, including translating best practice guidelines
2400into practice; reviewing prescriber patterns and comparing them
2401to indicators that are based on national standards and practice
2402patterns of clinical peers in their community, statewide, and
2403nationally; and determine deviations from best practice
2405     (II)  Implement processes for providing feedback to and
2406educating prescribers using best practice educational materials
2407and peer-to-peer consultation.
2408     (III)  Assess Medicaid recipients who are outliers in their
2409use of a single or multiple prescription drugs with regard to
2410the numbers and types of drugs taken, drug dosages, combination
2411drug therapies, and other indicators of improper use of
2412prescription drugs.
2413     (IV)  Alert prescribers to patients who fail to refill
2414prescriptions in a timely fashion, are prescribed multiple drugs
2415that may be redundant or contraindicated, or may have other
2416potential medication problems.
2417     (V)  Track spending trends for prescription drugs and
2418deviation from best practice guidelines.
2419     (VI)  Use educational and technological approaches to
2420promote best practices, educate consumers, and train prescribers
2421in the use of practice guidelines.
2422     (VII)  Disseminate electronic and published materials.
2423     (VIII)  Hold statewide and regional conferences.
2424     (IX)  Implement disease management programs in cooperation
2425with physicians and pharmacists, along with a model quality-
2426based medication component for individuals having chronic
2427medical conditions.
2428     12.  The agency is authorized to contract for drug rebate
2429administration, including, but not limited to, calculating
2430rebate amounts, invoicing manufacturers, negotiating disputes
2431with manufacturers, and maintaining a database of rebate
2433     13.  The agency may specify the preferred daily dosing form
2434or strength for the purpose of promoting best practices with
2435regard to the prescribing of certain drugs as specified in the
2436General Appropriations Act and ensuring cost-effective
2437prescribing practices.
2438     14.  The agency may require prior authorization for
2439Medicaid-covered prescribed drugs. The agency may, but is not
2440required to, prior-authorize the use of a product:
2441     a.  For an indication not approved in labeling;
2442     b.  To comply with certain clinical guidelines; or
2443     c.  If the product has the potential for overuse, misuse,
2444or abuse.
2446The agency may require the prescribing professional to provide
2447information about the rationale and supporting medical evidence
2448for the use of a drug. The agency may post prior authorization
2449criteria and protocol and updates to the list of drugs that are
2450subject to prior authorization on an Internet website without
2451amending its rule or engaging in additional rulemaking.
2452     15.  The agency, in conjunction with the Pharmaceutical and
2453Therapeutics Committee, may require age-related prior
2454authorizations for certain prescribed drugs. The agency may
2455preauthorize the use of a drug for a recipient who may not meet
2456the age requirement or may exceed the length of therapy for use
2457of this product as recommended by the manufacturer and approved
2458by the Food and Drug Administration. Prior authorization may
2459require the prescribing professional to provide information
2460about the rationale and supporting medical evidence for the use
2461of a drug.
2462     16.  The agency shall implement a step-therapy prior
2463authorization approval process for medications excluded from the
2464preferred drug list. Medications listed on the preferred drug
2465list must be used within the previous 12 months prior to the
2466alternative medications that are not listed. The step-therapy
2467prior authorization may require the prescriber to use the
2468medications of a similar drug class or for a similar medical
2469indication unless contraindicated in the Food and Drug
2470Administration labeling. The trial period between the specified
2471steps may vary according to the medical indication. The step-
2472therapy approval process shall be developed in accordance with
2473the committee as stated in s. 409.91195(7) and (8). A drug
2474product may be approved without meeting the step-therapy prior
2475authorization criteria if the prescribing physician provides the
2476agency with additional written medical or clinical documentation
2477that the product is medically necessary because:
2478     a.  There is not a drug on the preferred drug list to treat
2479the disease or medical condition which is an acceptable clinical
2481     b.  The alternatives have been ineffective in the treatment
2482of the beneficiary's disease; or
2483     c.  Based on historic evidence and known characteristics of
2484the patient and the drug, the drug is likely to be ineffective,
2485or the number of doses have been ineffective.
2487The agency shall work with the physician to determine the best
2488alternative for the patient. The agency may adopt rules waiving
2489the requirements for written clinical documentation for specific
2490drugs in limited clinical situations.
2491     17.  The agency shall implement a return and reuse program
2492for drugs dispensed by pharmacies to institutional recipients,
2493which includes payment of a $5 restocking fee for the
2494implementation and operation of the program. The return and
2495reuse program shall be implemented electronically and in a
2496manner that promotes efficiency. The program must permit a
2497pharmacy to exclude drugs from the program if it is not
2498practical or cost-effective for the drug to be included and must
2499provide for the return to inventory of drugs that cannot be
2500credited or returned in a cost-effective manner. The agency
2501shall determine if the program has reduced the amount of
2502Medicaid prescription drugs which are destroyed on an annual
2503basis and if there are additional ways to ensure more
2504prescription drugs are not destroyed which could safely be
2505reused. The agency's conclusion and recommendations shall be
2506reported to the Legislature by December 1, 2005.
2507     (b)  The agency shall implement this subsection to the
2508extent that funds are appropriated to administer the Medicaid
2509prescribed-drug spending-control program. The agency may
2510contract all or any part of this program to private
2512     (c)  The agency shall submit quarterly reports to the
2513Governor, the President of the Senate, and the Speaker of the
2514House of Representatives which must include, but need not be
2515limited to, the progress made in implementing this subsection
2516and its effect on Medicaid prescribed-drug expenditures.
2517     (38)(40)  Notwithstanding the provisions of chapter 287,
2518the agency may, at its discretion, renew a contract or contracts
2519for fiscal intermediary services one or more times for such
2520periods as the agency may decide; however, all such renewals may
2521not combine to exceed a total period longer than the term of the
2522original contract.
2523     (39)(41)  The agency shall provide for the development of a
2524demonstration project by establishment in Miami-Dade County of a
2525long-term-care facility licensed pursuant to chapter 395 to
2526improve access to health care for a predominantly minority,
2527medically underserved, and medically complex population and to
2528evaluate alternatives to nursing home care and general acute
2529care for such population. Such project is to be located in a
2530health care condominium and colocated with licensed facilities
2531providing a continuum of care. The establishment of this project
2532is not subject to the provisions of s. 408.036 or s. 408.039.
2533This subsection expires October 1, 2013.
2534     (40)(42)  The agency shall develop and implement a
2535utilization management program for Medicaid-eligible recipients
2536for the management of occupational, physical, respiratory, and
2537speech therapies. The agency shall establish a utilization
2538program that may require prior authorization in order to ensure
2539medically necessary and cost-effective treatments. The program
2540shall be operated in accordance with a federally approved waiver
2541program or state plan amendment. The agency may seek a federal
2542waiver or state plan amendment to implement this program. The
2543agency may also competitively procure these services from an
2544outside vendor on a regional or statewide basis. This subsection
2545expires October 1, 2014.
2546     (41)(43)  The agency shall may contract on a prepaid or
2547fixed-sum basis with appropriately licensed prepaid dental
2548health plans to provide dental services. This subsection expires
2549October 1, 2014.
2550     (42)(44)  The Agency for Health Care Administration shall
2551ensure that any Medicaid managed care plan as defined in s.
2552409.9122(2)(f), whether paid on a capitated basis or a shared
2553savings basis, is cost-effective. For purposes of this
2554subsection, the term "cost-effective" means that a network's
2555per-member, per-month costs to the state, including, but not
2556limited to, fee-for-service costs, administrative costs, and
2557case-management fees, if any, must be no greater than the
2558state's costs associated with contracts for Medicaid services
2559established under subsection (3), which may be adjusted for
2560health status. The agency shall conduct actuarially sound
2561adjustments for health status in order to ensure such cost-
2562effectiveness and shall annually publish the results on its
2563Internet website. Contracts established pursuant to this
2564subsection which are not cost-effective may not be renewed. This
2565subsection expires October 1, 2014.
2566     (43)(45)  Subject to the availability of funds, the agency
2567shall mandate a recipient's participation in a provider lock-in
2568program, when appropriate, if a recipient is found by the agency
2569to have used Medicaid goods or services at a frequency or amount
2570not medically necessary, limiting the receipt of goods or
2571services to medically necessary providers after the 21-day
2572appeal process has ended, for a period of not less than 1 year.
2573The lock-in programs shall include, but are not limited to,
2574pharmacies, medical doctors, and infusion clinics. The
2575limitation does not apply to emergency services and care
2576provided to the recipient in a hospital emergency department.
2577The agency shall seek any federal waivers necessary to implement
2578this subsection. The agency shall adopt any rules necessary to
2579comply with or administer this subsection. This subsection
2580expires October 1, 2014.
2581     (44)(46)  The agency shall seek a federal waiver for
2582permission to terminate the eligibility of a Medicaid recipient
2583who has been found to have committed fraud, through judicial or
2584administrative determination, two times in a period of 5 years.
2585     (47)  The agency shall conduct a study of available
2586electronic systems for the purpose of verifying the identity and
2587eligibility of a Medicaid recipient. The agency shall recommend
2588to the Legislature a plan to implement an electronic
2589verification system for Medicaid recipients by January 31, 2005.
2590     (45)(48)(a)  A provider is not entitled to enrollment in
2591the Medicaid provider network. The agency may implement a
2592Medicaid fee-for-service provider network controls, including,
2593but not limited to, competitive procurement and provider
2594credentialing. If a credentialing process is used, the agency
2595may limit its provider network based upon the following
2596considerations: beneficiary access to care, provider
2597availability, provider quality standards and quality assurance
2598processes, cultural competency, demographic characteristics of
2599beneficiaries, practice standards, service wait times, provider
2600turnover, provider licensure and accreditation history, program
2601integrity history, peer review, Medicaid policy and billing
2602compliance records, clinical and medical record audit findings,
2603and such other areas that are considered necessary by the agency
2604to ensure the integrity of the program.
2605     (b)  The agency shall limit its network of durable medical
2606equipment and medical supply providers. For dates of service
2607after January 1, 2009, the agency shall limit payment for
2608durable medical equipment and supplies to providers that meet
2609all the requirements of this paragraph.
2610     1.  Providers must be accredited by a Centers for Medicare
2611and Medicaid Services deemed accreditation organization for
2612suppliers of durable medical equipment, prosthetics, orthotics,
2613and supplies. The provider must maintain accreditation and is
2614subject to unannounced reviews by the accrediting organization.
2615     2.  Providers must provide the services or supplies
2616directly to the Medicaid recipient or caregiver at the provider
2617location or recipient's residence or send the supplies directly
2618to the recipient's residence with receipt of mailed delivery.
2619Subcontracting or consignment of the service or supply to a
2620third party is prohibited.
2621     3.  Notwithstanding subparagraph 2., a durable medical
2622equipment provider may store nebulizers at a physician's office
2623for the purpose of having the physician's staff issue the
2624equipment if it meets all of the following conditions:
2625     a.  The physician must document the medical necessity and
2626need to prevent further deterioration of the patient's
2627respiratory status by the timely delivery of the nebulizer in
2628the physician's office.
2629     b.  The durable medical equipment provider must have
2630written documentation of the competency and training by a
2631Florida-licensed registered respiratory therapist of any durable
2632medical equipment staff who participate in the training of
2633physician office staff for the use of nebulizers, including
2634cleaning, warranty, and special needs of patients.
2635     c.  The physician's office must have documented the
2636training and competency of any staff member who initiates the
2637delivery of nebulizers to patients. The durable medical
2638equipment provider must maintain copies of all physician office
2640     d.  The physician's office must maintain inventory records
2641of stored nebulizers, including documentation of the durable
2642medical equipment provider source.
2643     e.  A physician contracted with a Medicaid durable medical
2644equipment provider may not have a financial relationship with
2645that provider or receive any financial gain from the delivery of
2646nebulizers to patients.
2647     4.  Providers must have a physical business location and a
2648functional landline business phone. The location must be within
2649the state or not more than 50 miles from the Florida state line.
2650The agency may make exceptions for providers of durable medical
2651equipment or supplies not otherwise available from other
2652enrolled providers located within the state.
2653     5.  Physical business locations must be clearly identified
2654as a business that furnishes durable medical equipment or
2655medical supplies by signage that can be read from 20 feet away.
2656The location must be readily accessible to the public during
2657normal, posted business hours and must operate at least 5 hours
2658per day and at least 5 days per week, with the exception of
2659scheduled and posted holidays. The location may not be located
2660within or at the same numbered street address as another
2661enrolled Medicaid durable medical equipment or medical supply
2662provider or as an enrolled Medicaid pharmacy that is also
2663enrolled as a durable medical equipment provider. A licensed
2664orthotist or prosthetist that provides only orthotic or
2665prosthetic devices as a Medicaid durable medical equipment
2666provider is exempt from this paragraph.
2667     6.  Providers must maintain a stock of durable medical
2668equipment and medical supplies on site that is readily available
2669to meet the needs of the durable medical equipment business
2670location's customers.
2671     7.  Providers must provide a surety bond of $50,000 for
2672each provider location, up to a maximum of 5 bonds statewide or
2673an aggregate bond of $250,000 statewide, as identified by
2674Federal Employer Identification Number. Providers who post a
2675statewide or an aggregate bond must identify all of their
2676locations in any Medicaid durable medical equipment and medical
2677supply provider enrollment application or bond renewal. Each
2678provider location's surety bond must be renewed annually and the
2679provider must submit proof of renewal even if the original bond
2680is a continuous bond. A licensed orthotist or prosthetist that
2681provides only orthotic or prosthetic devices as a Medicaid
2682durable medical equipment provider is exempt from the provisions
2683in this paragraph.
2684     8.  Providers must obtain a level 2 background screening,
2685in accordance with chapter 435 and s. 408.809, for each provider
2686employee in direct contact with or providing direct services to
2687recipients of durable medical equipment and medical supplies in
2688their homes. This requirement includes, but is not limited to,
2689repair and service technicians, fitters, and delivery staff. The
2690provider shall pay for the cost of the background screening.
2691     9.  The following providers are exempt from subparagraphs
26921. and 7.:
2693     a.  Durable medical equipment providers owned and operated
2694by a government entity.
2695     b.  Durable medical equipment providers that are operating
2696within a pharmacy that is currently enrolled as a Medicaid
2697pharmacy provider.
2698     c.  Active, Medicaid-enrolled orthopedic physician groups,
2699primarily owned by physicians, which provide only orthotic and
2700prosthetic devices.
2701     (46)(49)  The agency shall contract with established
2702minority physician networks that provide services to
2703historically underserved minority patients. The networks must
2704provide cost-effective Medicaid services, comply with the
2705requirements to be a MediPass provider, and provide their
2706primary care physicians with access to data and other management
2707tools necessary to assist them in ensuring the appropriate use
2708of services, including inpatient hospital services and
2710     (a)  The agency shall provide for the development and
2711expansion of minority physician networks in each service area to
2712provide services to Medicaid recipients who are eligible to
2713participate under federal law and rules.
2714     (b)  The agency shall reimburse each minority physician
2715network as a fee-for-service provider, including the case
2716management fee for primary care, if any, or as a capitated rate
2717provider for Medicaid services. Any savings shall be shared with
2718the minority physician networks pursuant to the contract.
2719     (c)  For purposes of this subsection, the term "cost-
2720effective" means that a network's per-member, per-month costs to
2721the state, including, but not limited to, fee-for-service costs,
2722administrative costs, and case-management fees, if any, must be
2723no greater than the state's costs associated with contracts for
2724Medicaid services established under subsection (3), which shall
2725be actuarially adjusted for case mix, model, and service area.
2726The agency shall conduct actuarially sound audits adjusted for
2727case mix and model in order to ensure such cost-effectiveness
2728and shall annually publish the audit results on its Internet
2729website. Contracts established pursuant to this subsection which
2730are not cost-effective may not be renewed.
2731     (d)  The agency may apply for any federal waivers needed to
2732implement this subsection.
2734This subsection expires October 1, 2014.
2735     (47)(50)  To the extent permitted by federal law and as
2736allowed under s. 409.906, the agency shall provide reimbursement
2737for emergency mental health care services for Medicaid
2738recipients in crisis stabilization facilities licensed under s.
2739394.875 as long as those services are less expensive than the
2740same services provided in a hospital setting.
2741     (48)(51)  The agency shall work with the Agency for Persons
2742with Disabilities to develop a home and community-based waiver
2743to serve children and adults who are diagnosed with familial
2744dysautonomia or Riley-Day syndrome caused by a mutation of the
2745IKBKAP gene on chromosome 9. The agency shall seek federal
2746waiver approval and implement the approved waiver subject to the
2747availability of funds and any limitations provided in the
2748General Appropriations Act. The agency may adopt rules to
2749implement this waiver program.
2750     (49)(52)  The agency shall implement a program of all-
2751inclusive care for children. The program of all-inclusive care
2752for children shall be established to provide in-home hospice-
2753like support services to children diagnosed with a life-
2754threatening illness and enrolled in the Children's Medical
2755Services network to reduce hospitalizations as appropriate. The
2756agency, in consultation with the Department of Health, may
2757implement the program of all-inclusive care for children after
2758obtaining approval from the Centers for Medicare and Medicaid
2760     (50)(53)  Before seeking an amendment to the state plan for
2761purposes of implementing programs authorized by the Deficit
2762Reduction Act of 2005, the agency shall notify the Legislature.
2763     (51)  The agency may not pay for psychotropic medication
2764prescribed for a child in the Medicaid program without the
2765express and informed consent of the child's parent or legal
2766guardian. The physician shall document the consent in the
2767child's medical record and provide the pharmacy with a signed
2768attestation of this documentation with the prescription. The
2769express and informed consent or court authorization for a
2770prescription of psychotropic medication for a child in the
2771custody of the Department of Children and Family Services shall
2772be obtained pursuant to s. 39.407.
2773     Section 18.  Section 409.91207, Florida Statutes, is
2775     Section 19.  Paragraphs (e), (l), (p), (w), and (dd) of
2776subsection (3) of section 409.91211, Florida Statutes, are
2777amended to read:
2778     409.91211  Medicaid managed care pilot program.-
2779     (3)  The agency shall have the following powers, duties,
2780and responsibilities with respect to the pilot program:
2781     (e)  To implement policies and guidelines for phasing in
2782financial risk for approved provider service networks that, for
2783purposes of this paragraph, include the Children's Medical
2784Services Network, over the period of the waiver and the
2785extension thereof. These policies and guidelines must include an
2786option for a provider service network to be paid fee-for-service
2787rates. For any provider service network established in a managed
2788care pilot area, the option to be paid fee-for-service rates
2789must include a savings-settlement mechanism that is consistent
2790with s. 409.912(42)(44). This model must be converted to a risk-
2791adjusted capitated rate by the beginning of the final year of
2792operation under the waiver extension, and may be converted
2793earlier at the option of the provider service network. Federally
2794qualified health centers may be offered an opportunity to accept
2795or decline a contract to participate in any provider network for
2796prepaid primary care services.
2797     (l)  To implement a system that prohibits capitated managed
2798care plans, their representatives, and providers employed by or
2799contracted with the capitated managed care plans from recruiting
2800persons eligible for or enrolled in Medicaid, from providing
2801inducements to Medicaid recipients to select a particular
2802capitated managed care plan, and from prejudicing Medicaid
2803recipients against other capitated managed care plans. The
2804system shall require the entity performing choice counseling to
2805determine if the recipient has made a choice of a plan or has
2806opted out because of duress, threats, payment to the recipient,
2807or incentives promised to the recipient by a third party. If the
2808choice counseling entity determines that the decision to choose
2809a plan was unlawfully influenced or a plan violated any of the
2810provisions of s. 409.912(20)(21), the choice counseling entity
2811shall immediately report the violation to the agency's program
2812integrity section for investigation. Verification of choice
2813counseling by the recipient shall include a stipulation that the
2814recipient acknowledges the provisions of this subsection.
2815     (p)  To implement standards for plan compliance, including,
2816but not limited to, standards for quality assurance and
2817performance improvement, standards for peer or professional
2818reviews, grievance policies, and policies for maintaining
2819program integrity. The agency shall develop a data-reporting
2820system, seek input from managed care plans in order to establish
2821requirements for patient-encounter reporting, and ensure that
2822the data reported is accurate and complete.
2823     1.  In performing the duties required under this section,
2824the agency shall work with managed care plans to establish a
2825uniform system to measure and monitor outcomes for a recipient
2826of Medicaid services.
2827     2.  The system shall use financial, clinical, and other
2828criteria based on pharmacy, medical services, and other data
2829that is related to the provision of Medicaid services,
2830including, but not limited to:
2831     a.  The Health Plan Employer Data and Information Set
2832(HEDIS) or measures that are similar to HEDIS.
2833     b.  Member satisfaction.
2834     c.  Provider satisfaction.
2835     d.  Report cards on plan performance and best practices.
2836     e.  Compliance with the requirements for prompt payment of
2837claims under ss. 627.613, 641.3155, and 641.513.
2838     f.  Utilization and quality data for the purpose of
2839ensuring access to medically necessary services, including
2840underutilization or inappropriate denial of services.
2841     3.  The agency shall require the managed care plans that
2842have contracted with the agency to establish a quality assurance
2843system that incorporates the provisions of s. 409.912(26)(27)
2844and any standards, rules, and guidelines developed by the
2846     4.  The agency shall establish an encounter database in
2847order to compile data on health services rendered by health care
2848practitioners who provide services to patients enrolled in
2849managed care plans in the demonstration sites. The encounter
2850database shall:
2851     a.  Collect the following for each type of patient
2852encounter with a health care practitioner or facility,
2854     (I)  The demographic characteristics of the patient.
2855     (II)  The principal, secondary, and tertiary diagnosis.
2856     (III)  The procedure performed.
2857     (IV)  The date and location where the procedure was
2859     (V)  The payment for the procedure, if any.
2860     (VI)  If applicable, the health care practitioner's
2861universal identification number.
2862     (VII)  If the health care practitioner rendering the
2863service is a dependent practitioner, the modifiers appropriate
2864to indicate that the service was delivered by the dependent
2866     b.  Collect appropriate information relating to
2867prescription drugs for each type of patient encounter.
2868     c.  Collect appropriate information related to health care
2869costs and utilization from managed care plans participating in
2870the demonstration sites.
2871     5.  To the extent practicable, when collecting the data the
2872agency shall use a standardized claim form or electronic
2873transfer system that is used by health care practitioners,
2874facilities, and payors.
2875     6.  Health care practitioners and facilities in the
2876demonstration sites shall electronically submit, and managed
2877care plans participating in the demonstration sites shall
2878electronically receive, information concerning claims payments
2879and any other information reasonably related to the encounter
2880database using a standard format as required by the agency.
2881     7.  The agency shall establish reasonable deadlines for
2882phasing in the electronic transmittal of full encounter data.
2883     8.  The system must ensure that the data reported is
2884accurate and complete.
2885     (w)  To implement procedures to minimize the risk of
2886Medicaid fraud and abuse in all plans operating in the Medicaid
2887managed care pilot program authorized in this section.
2888     1.  The agency shall ensure that applicable provisions of
2889this chapter and chapters 414, 626, 641, and 932 which relate to
2890Medicaid fraud and abuse are applied and enforced at the
2891demonstration project sites.
2892     2.  Providers must have the certification, license, and
2893credentials that are required by law and waiver requirements.
2894     3.  The agency shall ensure that the plan is in compliance
2895with s. 409.912(20) and (21) and (22).
2896     4.  The agency shall require that each plan establish
2897functions and activities governing program integrity in order to
2898reduce the incidence of fraud and abuse. Plans must report
2899instances of fraud and abuse pursuant to chapter 641.
2900     5.  The plan shall have written administrative and
2901management arrangements or procedures, including a mandatory
2902compliance plan, which are designed to guard against fraud and
2903abuse. The plan shall designate a compliance officer who has
2904sufficient experience in health care.
2905     6.a.  The agency shall require all managed care plan
2906contractors in the pilot program to report all instances of
2907suspected fraud and abuse. A failure to report instances of
2908suspected fraud and abuse is a violation of law and subject to
2909the penalties provided by law.
2910     b.  An instance of fraud and abuse in the managed care
2911plan, including, but not limited to, defrauding the state health
2912care benefit program by misrepresentation of fact in reports,
2913claims, certifications, enrollment claims, demographic
2914statistics, or patient-encounter data; misrepresentation of the
2915qualifications of persons rendering health care and ancillary
2916services; bribery and false statements relating to the delivery
2917of health care; unfair and deceptive marketing practices; and
2918false claims actions in the provision of managed care, is a
2919violation of law and subject to the penalties provided by law.
2920     c.  The agency shall require that all contractors make all
2921files and relevant billing and claims data accessible to state
2922regulators and investigators and that all such data is linked
2923into a unified system to ensure consistent reviews and
2925     (dd)  To implement service delivery mechanisms within a
2926specialty plan in area 10 to provide behavioral health care
2927services to Medicaid-eligible children whose cases are open for
2928child welfare services in the HomeSafeNet system. These services
2929must be coordinated with community-based care providers as
2930specified in s. 409.1671, where available, and be sufficient to
2931meet the developmental, behavioral, and emotional needs of these
2932children. Children in area 10 who have an open case in the
2933HomeSafeNet system shall be enrolled into the specialty plan.
2934These service delivery mechanisms must be implemented no later
2935than July 1, 2011, in AHCA area 10 in order for the children in
2936AHCA area 10 to remain exempt from the statewide plan under s.
2937409.912(4)(b)5.8. An administrative fee may be paid to the
2938specialty plan for the coordination of services based on the
2939receipt of the state share of that fee being provided through
2940intergovernmental transfers.
2941     Section 20.  Effective October 1, 2014, section 409.91211,
2942Florida Statutes, is repealed.
2943     Section 21.  Section 409.9122, Florida Statutes, is amended
2944to read:
2945     409.9122  Mandatory Medicaid managed care enrollment;
2946programs and procedures.-
2947     (1)  It is the intent of the Legislature that the MediPass
2948program be cost-effective, provide quality health care, and
2949improve access to health services, and that the program be
2950statewide. This subsection expires October 1, 2014.
2951     (2)(a)  The agency shall enroll in a managed care plan or
2952MediPass all Medicaid recipients, except those Medicaid
2953recipients who are: in an institution; enrolled in the Medicaid
2954medically needy program; or eligible for both Medicaid and
2955Medicare. Upon enrollment, individuals will be able to change
2956their managed care option during the 90-day opt out period
2957required by federal Medicaid regulations. The agency is
2958authorized to seek the necessary Medicaid state plan amendment
2959to implement this policy. However, to the extent permitted by
2960federal law, the agency may enroll in a managed care plan or
2961MediPass a Medicaid recipient who is exempt from mandatory
2962managed care enrollment, provided that:
2963     1.  The recipient's decision to enroll in a managed care
2964plan or MediPass is voluntary;
2965     2.  If the recipient chooses to enroll in a managed care
2966plan, the agency has determined that the managed care plan
2967provides specific programs and services which address the
2968special health needs of the recipient; and
2969     3.  The agency receives any necessary waivers from the
2970federal Centers for Medicare and Medicaid Services.
2972The agency shall develop rules to establish policies by which
2973exceptions to the mandatory managed care enrollment requirement
2974may be made on a case-by-case basis. The rules shall include the
2975specific criteria to be applied when making a determination as
2976to whether to exempt a recipient from mandatory enrollment in a
2977managed care plan or MediPass. School districts participating in
2978the certified school match program pursuant to ss. 409.908(21)
2979and 1011.70 shall be reimbursed by Medicaid, subject to the
2980limitations of s. 1011.70(1), for a Medicaid-eligible child
2981participating in the services as authorized in s. 1011.70, as
2982provided for in s. 409.9071, regardless of whether the child is
2983enrolled in MediPass or a managed care plan. Managed care plans
2984shall make a good faith effort to execute agreements with school
2985districts regarding the coordinated provision of services
2986authorized under s. 1011.70. County health departments
2987delivering school-based services pursuant to ss. 381.0056 and
2988381.0057 shall be reimbursed by Medicaid for the federal share
2989for a Medicaid-eligible child who receives Medicaid-covered
2990services in a school setting, regardless of whether the child is
2991enrolled in MediPass or a managed care plan. Managed care plans
2992shall make a good faith effort to execute agreements with county
2993health departments regarding the coordinated provision of
2994services to a Medicaid-eligible child. To ensure continuity of
2995care for Medicaid patients, the agency, the Department of
2996Health, and the Department of Education shall develop procedures
2997for ensuring that a student's managed care plan or MediPass
2998provider receives information relating to services provided in
2999accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
3000     (b)  A Medicaid recipient shall not be enrolled in or
3001assigned to a managed care plan or MediPass unless the managed
3002care plan or MediPass has complied with the quality-of-care
3003standards specified in paragraphs (3)(a) and (b), respectively.
3004     (c)  Medicaid recipients shall have a choice of managed
3005care plans or MediPass. The Agency for Health Care
3006Administration, the Department of Health, the Department of
3007Children and Family Services, and the Department of Elderly
3008Affairs shall cooperate to ensure that each Medicaid recipient
3009receives clear and easily understandable information that meets
3010the following requirements:
3011     1.  Explains the concept of managed care, including
3013     2.  Provides information on the comparative performance of
3014managed care plans and MediPass in the areas of quality,
3015credentialing, preventive health programs, network size and
3016availability, and patient satisfaction.
3017     3.  Explains where additional information on each managed
3018care plan and MediPass in the recipient's area can be obtained.
3019     4.  Explains that recipients have the right to choose their
3020managed care coverage at the time they first enroll in Medicaid
3021and again at regular intervals set by the agency. However, if a
3022recipient does not choose a managed care plan or MediPass, the
3023agency will assign the recipient to a managed care plan or
3024MediPass according to the criteria specified in this section.
3025     5.  Explains the recipient's right to complain, file a
3026grievance, or change managed care plans or MediPass providers if
3027the recipient is not satisfied with the managed care plan or
3029     (d)  The agency shall develop a mechanism for providing
3030information to Medicaid recipients for the purpose of making a
3031managed care plan or MediPass selection. Examples of such
3032mechanisms may include, but not be limited to, interactive
3033information systems, mailings, and mass marketing materials.
3034Managed care plans and MediPass providers are prohibited from
3035providing inducements to Medicaid recipients to select their
3036plans or from prejudicing Medicaid recipients against other
3037managed care plans or MediPass providers.
3038     (e)  Medicaid recipients who are already enrolled in a
3039managed care plan or MediPass shall be offered the opportunity
3040to change managed care plans or MediPass providers on a
3041staggered basis, as defined by the agency. All Medicaid
3042recipients shall have 30 days in which to make a choice of
3043managed care plans or MediPass providers. Those Medicaid
3044recipients who do not make a choice shall be assigned in
3045accordance with paragraph (f). To facilitate continuity of care,
3046for a Medicaid recipient who is also a recipient of Supplemental
3047Security Income (SSI), prior to assigning the SSI recipient to a
3048managed care plan or MediPass, the agency shall determine
3049whether the SSI recipient has an ongoing relationship with a
3050MediPass provider or managed care plan, and if so, the agency
3051shall assign the SSI recipient to that MediPass provider or
3052managed care plan. Those SSI recipients who do not have such a
3053provider relationship shall be assigned to a managed care plan
3054or MediPass provider in accordance with paragraph (f).
3055     (f)  If a Medicaid recipient does not choose a managed care
3056plan or MediPass provider, the agency shall assign the Medicaid
3057recipient to a managed care plan or MediPass provider. Medicaid
3058recipients eligible for managed care plan enrollment who are
3059subject to mandatory assignment but who fail to make a choice
3060shall be assigned to managed care plans until an enrollment of
306135 percent in MediPass and 65 percent in managed care plans, of
3062all those eligible to choose managed care, is achieved. Once
3063this enrollment is achieved, the assignments shall be divided in
3064order to maintain an enrollment in MediPass and managed care
3065plans which is in a 35 percent and 65 percent proportion,
3066respectively. Thereafter, assignment of Medicaid recipients who
3067fail to make a choice shall be based proportionally on the
3068preferences of recipients who have made a choice in the previous
3069period. Such proportions shall be revised at least quarterly to
3070reflect an update of the preferences of Medicaid recipients. The
3071agency shall disproportionately assign Medicaid-eligible
3072recipients who are required to but have failed to make a choice
3073of managed care plan or MediPass, including children, and who
3074would be assigned to the MediPass program to the children's
3075networks as described in s. 409.912(4)(g), Children's Medical
3076Services Network as defined in s. 391.021, exclusive provider
3077organizations, provider service networks, minority physician
3078networks, and pediatric emergency department diversion programs
3079authorized by this chapter or the General Appropriations Act, in
3080such manner as the agency deems appropriate, until the agency
3081has determined that the networks and programs have sufficient
3082numbers to be operated economically. For purposes of this
3083paragraph, when referring to assignment, the term "managed care
3084plans" includes health maintenance organizations, exclusive
3085provider organizations, provider service networks, minority
3086physician networks, Children's Medical Services Network, and
3087pediatric emergency department diversion programs authorized by
3088this chapter or the General Appropriations Act. When making
3089assignments, the agency shall take into account the following
3091     1.  A managed care plan has sufficient network capacity to
3092meet the need of members.
3093     2.  The managed care plan or MediPass has previously
3094enrolled the recipient as a member, or one of the managed care
3095plan's primary care providers or MediPass providers has
3096previously provided health care to the recipient.
3097     3.  The agency has knowledge that the member has previously
3098expressed a preference for a particular managed care plan or
3099MediPass provider as indicated by Medicaid fee-for-service
3100claims data, but has failed to make a choice.
3101     4.  The managed care plan's or MediPass primary care
3102providers are geographically accessible to the recipient's
3104     (g)  When more than one managed care plan or MediPass
3105provider meets the criteria specified in paragraph (f), the
3106agency shall make recipient assignments consecutively by family
3108     (h)  The agency may not engage in practices that are
3109designed to favor one managed care plan over another or that are
3110designed to influence Medicaid recipients to enroll in MediPass
3111rather than in a managed care plan or to enroll in a managed
3112care plan rather than in MediPass. This subsection does not
3113prohibit the agency from reporting on the performance of
3114MediPass or any managed care plan, as measured by performance
3115criteria developed by the agency.
3116     (i)  After a recipient has made his or her selection or has
3117been enrolled in a managed care plan or MediPass, the recipient
3118shall have 90 days to exercise the opportunity to voluntarily
3119disenroll and select another managed care plan or MediPass.
3120After 90 days, no further changes may be made except for good
3121cause. Good cause includes, but is not limited to, poor quality
3122of care, lack of access to necessary specialty services, an
3123unreasonable delay or denial of service, or fraudulent
3124enrollment. The agency shall develop criteria for good cause
3125disenrollment for chronically ill and disabled populations who
3126are assigned to managed care plans if more appropriate care is
3127available through the MediPass program. The agency must make a
3128determination as to whether cause exists. However, the agency
3129may require a recipient to use the managed care plan's or
3130MediPass grievance process prior to the agency's determination
3131of cause, except in cases in which immediate risk of permanent
3132damage to the recipient's health is alleged. The grievance
3133process, when utilized, must be completed in time to permit the
3134recipient to disenroll by the first day of the second month
3135after the month the disenrollment request was made. If the
3136managed care plan or MediPass, as a result of the grievance
3137process, approves an enrollee's request to disenroll, the agency
3138is not required to make a determination in the case. The agency
3139must make a determination and take final action on a recipient's
3140request so that disenrollment occurs no later than the first day
3141of the second month after the month the request was made. If the
3142agency fails to act within the specified timeframe, the
3143recipient's request to disenroll is deemed to be approved as of
3144the date agency action was required. Recipients who disagree
3145with the agency's finding that cause does not exist for
3146disenrollment shall be advised of their right to pursue a
3147Medicaid fair hearing to dispute the agency's finding.
3148     (j)  The agency shall apply for a federal waiver from the
3149Centers for Medicare and Medicaid Services to lock eligible
3150Medicaid recipients into a managed care plan or MediPass for 12
3151months after an open enrollment period. After 12 months'
3152enrollment, a recipient may select another managed care plan or
3153MediPass provider. However, nothing shall prevent a Medicaid
3154recipient from changing primary care providers within the
3155managed care plan or MediPass program during the 12-month
3157     (k)  When a Medicaid recipient does not choose a managed
3158care plan or MediPass provider, the agency shall assign the
3159Medicaid recipient to a managed care plan, except in those
3160counties in which there are fewer than two managed care plans
3161accepting Medicaid enrollees, in which case assignment shall be
3162to a managed care plan or a MediPass provider. Medicaid
3163recipients in counties with fewer than two managed care plans
3164accepting Medicaid enrollees who are subject to mandatory
3165assignment but who fail to make a choice shall be assigned to
3166managed care plans until an enrollment of 35 percent in MediPass
3167and 65 percent in managed care plans, of all those eligible to
3168choose managed care, is achieved. Once that enrollment is
3169achieved, the assignments shall be divided in order to maintain
3170an enrollment in MediPass and managed care plans which is in a
317135 percent and 65 percent proportion, respectively. For purposes
3172of this paragraph, when referring to assignment, the term
3173"managed care plans" includes exclusive provider organizations,
3174provider service networks, Children's Medical Services Network,
3175minority physician networks, and pediatric emergency department
3176diversion programs authorized by this chapter or the General
3177Appropriations Act. When making assignments, the agency shall
3178take into account the following criteria:
3179     1.  A managed care plan has sufficient network capacity to
3180meet the need of members.
3181     2.  The managed care plan or MediPass has previously
3182enrolled the recipient as a member, or one of the managed care
3183plan's primary care providers or MediPass providers has
3184previously provided health care to the recipient.
3185     3.  The agency has knowledge that the member has previously
3186expressed a preference for a particular managed care plan or
3187MediPass provider as indicated by Medicaid fee-for-service
3188claims data, but has failed to make a choice.
3189     4.  The managed care plan's or MediPass primary care
3190providers are geographically accessible to the recipient's
3192     5.  The agency has authority to make mandatory assignments
3193based on quality of service and performance of managed care
3195     (l)  If the Medicaid recipient is diagnosed with HIV/AIDS
3196and resides in Broward, Miami-Dade, or Palm Beach Counties, the
3197agency shall assign the Medicaid recipient to a managed care
3198plan that is a health maintenance organization authorized under
3199chapter 641, is under contract with the agency on July 1, 2011,
3200and offers a delivery system through a university-based teaching
3201and research-oriented organization that specializes in providing
3202health care services and treatment for individuals diagnosed
3203with HIV/AIDS.
3204     (m)(l)  Notwithstanding the provisions of chapter 287, the
3205agency may, at its discretion, renew cost-effective contracts
3206for choice counseling services once or more for such periods as
3207the agency may decide. However, all such renewals may not
3208combine to exceed a total period longer than the term of the
3209original contract.
3211This subsection expires October 1, 2014.
3212     (3)(a)  The agency shall establish quality-of-care
3213standards for managed care plans. These standards shall be based
3214upon, but are not limited to:
3215     1.  Compliance with the accreditation requirements as
3216provided in s. 641.512.
3217     2.  Compliance with Early and Periodic Screening,
3218Diagnosis, and Treatment screening requirements.
3219     3.  The percentage of voluntary disenrollments.
3220     4.  Immunization rates.
3221     5.  Standards of the National Committee for Quality
3222Assurance and other approved accrediting bodies.
3223     6.  Recommendations of other authoritative bodies.
3224     7.  Specific requirements of the Medicaid program, or
3225standards designed to specifically assist the unique needs of
3226Medicaid recipients.
3227     8.  Compliance with the health quality improvement system
3228as established by the agency, which incorporates standards and
3229guidelines developed by the Medicaid Bureau of the Health Care
3230Financing Administration as part of the quality assurance reform
3232     (b)  For the MediPass program, the agency shall establish
3233standards which are based upon, but are not limited to:
3234     1.  Quality-of-care standards which are comparable to those
3235required of managed care plans.
3236     2.  Credentialing standards for MediPass providers.
3237     3.  Compliance with Early and Periodic Screening,
3238Diagnosis, and Treatment screening requirements.
3239     4.  Immunization rates.
3240     5.  Specific requirements of the Medicaid program, or
3241standards designed to specifically assist the unique needs of
3242Medicaid recipients.
3244This subsection expires October 1, 2014.
3245     (4)(a)  Each female recipient may select as her primary
3246care provider an obstetrician/gynecologist who has agreed to
3247participate as a MediPass primary care case manager.
3248     (b)  The agency shall establish a complaints and grievance
3249process to assist Medicaid recipients enrolled in the MediPass
3250program to resolve complaints and grievances. The agency shall
3251investigate reports of quality-of-care grievances which remain
3252unresolved to the satisfaction of the enrollee.
3254This subsection expires October 1, 2014.
3255     (5)(a)  The agency shall work cooperatively with the Social
3256Security Administration to identify beneficiaries who are
3257jointly eligible for Medicare and Medicaid and shall develop
3258cooperative programs to encourage these beneficiaries to enroll
3259in a Medicare participating health maintenance organization or
3260prepaid health plans.
3261     (b)  The agency shall work cooperatively with the
3262Department of Elderly Affairs to assess the potential cost-
3263effectiveness of providing MediPass to beneficiaries who are
3264jointly eligible for Medicare and Medicaid on a voluntary choice
3265basis. If the agency determines that enrollment of these
3266beneficiaries in MediPass has the potential for being cost-
3267effective for the state, the agency shall offer MediPass to
3268these beneficiaries on a voluntary choice basis in the counties
3269where MediPass operates.
3271This subsection expires October 1, 2014.
3272     (6)  MediPass enrolled recipients may receive up to 10
3273visits of reimbursable services by participating Medicaid
3274physicians licensed under chapter 460 and up to four visits of
3275reimbursable services by participating Medicaid physicians
3276licensed under chapter 461. Any further visits must be by prior
3277authorization by the MediPass primary care provider. However,
3278nothing in this subsection may be construed to increase the
3279total number of visits or the total amount of dollars per year
3280per person under current Medicaid rules, unless otherwise
3281provided for in the General Appropriations Act. This subsection
3282expires October 1, 2014.
3283     (7)  The agency shall investigate the feasibility of
3284developing managed care plan and MediPass options for the
3285following groups of Medicaid recipients:
3286     (a)  Pregnant women and infants.
3287     (b)  Elderly and disabled recipients, especially those who
3288are at risk of nursing home placement.
3289     (c)  Persons with developmental disabilities.
3290     (d)  Qualified Medicare beneficiaries.
3291     (e)  Adults who have chronic, high-cost medical conditions.
3292     (f)  Adults and children who have mental health problems.
3293     (g)  Other recipients for whom managed care plans and
3294MediPass offer the opportunity of more cost-effective care and
3295greater access to qualified providers.
3296     (8)(a)  The agency shall encourage the development of
3297public and private partnerships to foster the growth of health
3298maintenance organizations and prepaid health plans that will
3299provide high-quality health care to Medicaid recipients.
3300     (b)  Subject to the availability of moneys and any
3301limitations established by the General Appropriations Act or
3302chapter 216, the agency is authorized to enter into contracts
3303with traditional providers of health care to low-income persons
3304to assist such providers with the technical aspects of
3305cooperatively developing Medicaid prepaid health plans.
3306     1.  The agency may contract with disproportionate share
3307hospitals, county health departments, federally initiated or
3308federally funded community health centers, and counties that
3309operate either a hospital or a community clinic.
3310     2.  A contract may not be for more than $100,000 per year,
3311and no contract may be extended with any particular provider for
3312more than 2 years. The contract is intended only as seed or
3313development funding and requires a commitment from the
3314interested party.
3315     3.  A contract must require participation by at least one
3316community health clinic and one disproportionate share hospital.
3317     (7)(9)(a)  The agency shall develop and implement a
3318comprehensive plan to ensure that recipients are adequately
3319informed of their choices and rights under all Medicaid managed
3320care programs and that Medicaid managed care programs meet
3321acceptable standards of quality in patient care, patient
3322satisfaction, and financial solvency.
3323     (b)  The agency shall provide adequate means for informing
3324patients of their choice and rights under a managed care plan at
3325the time of eligibility determination.
3326     (c)  The agency shall require managed care plans and
3327MediPass providers to demonstrate and document plans and
3328activities, as defined by rule, including outreach and followup,
3329undertaken to ensure that Medicaid recipients receive the health
3330care service to which they are entitled.
3332This subsection expires October 1, 2014.
3333     (8)(10)  The agency shall consult with Medicaid consumers
3334and their representatives on an ongoing basis regarding
3335measurements of patient satisfaction, procedures for resolving
3336patient grievances, standards for ensuring quality of care,
3337mechanisms for providing patient access to services, and
3338policies affecting patient care. This subsection expires October
33391, 2014.
3340     (9)(11)  The agency may extend eligibility for Medicaid
3341recipients enrolled in licensed and accredited health
3342maintenance organizations for the duration of the enrollment
3343period or for 6 months, whichever is earlier, provided the
3344agency certifies that such an offer will not increase state
3345expenditures. This subsection expires October 1, 2013.
3346     (10)(12)  A managed care plan that has a Medicaid contract
3347shall at least annually review each primary care physician's
3348active patient load and shall ensure that additional Medicaid
3349recipients are not assigned to physicians who have a total
3350active patient load of more than 3,000 patients. As used in this
3351subsection, the term "active patient" means a patient who is
3352seen by the same primary care physician, or by a physician
3353assistant or advanced registered nurse practitioner under the
3354supervision of the primary care physician, at least three times
3355within a calendar year. Each primary care physician shall
3356annually certify to the managed care plan whether or not his or
3357her patient load exceeds the limits established under this
3358subsection and the managed care plan shall accept such
3359certification on face value as compliance with this subsection.
3360The agency shall accept the managed care plan's representations
3361that it is in compliance with this subsection based on the
3362certification of its primary care physicians, unless the agency
3363has an objective indication that access to primary care is being
3364compromised, such as receiving complaints or grievances relating
3365to access to care. If the agency determines that an objective
3366indication exists that access to primary care is being
3367compromised, it may verify the patient load certifications
3368submitted by the managed care plan's primary care physicians and
3369that the managed care plan is not assigning Medicaid recipients
3370to primary care physicians who have an active patient load of
3371more than 3,000 patients. This subsection expires October 1,
3373     (11)(13)  Effective July 1, 2003, the agency shall adjust
3374the enrollee assignment process of Medicaid managed prepaid
3375health plans for those Medicaid managed prepaid plans operating
3376in Miami-Dade County which have executed a contract with the
3377agency for a minimum of 8 consecutive years in order for the
3378Medicaid managed prepaid plan to maintain a minimum enrollment
3379level of 15,000 members per month. When assigning enrollees
3380pursuant to this subsection, the agency shall give priority to
3381providers that initially qualified under this subsection until
3382such providers reach and maintain an enrollment level of 15,000
3383members per month. A prepaid health plan that has a statewide
3384Medicaid enrollment of 25,000 or more members is not eligible
3385for enrollee assignments under this subsection. This subsection
3386expires October 1, 2014.
3387     (12)(14)  The agency shall include in its calculation of
3388the hospital inpatient component of a Medicaid health
3389maintenance organization's capitation rate any special payments,
3390including, but not limited to, upper payment limit or
3391disproportionate share hospital payments, made to qualifying
3392hospitals through the fee-for-service program. The agency may
3393seek federal waiver approval or state plan amendment as needed
3394to implement this adjustment.
3395     (13)  The agency shall develop a process to enable any
3396recipient with access to employer-sponsored health care coverage
3397to opt out of all eligible plans in the Medicaid program and to
3398use Medicaid financial assistance to pay for the recipient's
3399share of cost in any such employer-sponsored coverage.
3400Contingent on federal approval, the agency shall also enable
3401recipients with access to other insurance or related products
3402that provide access to health care services created pursuant to
3403state law, including any plan or product available pursuant to
3404the Florida Health Choices Program or any health exchange, to
3405opt out. The amount of financial assistance provided for each
3406recipient may not exceed the amount of the Medicaid premium that
3407would have been paid to a plan for that recipient.
3408     (14)  The agency shall maintain and operate the Medicaid
3409Encounter Data System to collect, process, store, and report on
3410covered services provided to all Florida Medicaid recipients
3411enrolled in prepaid managed care plans.
3412     (a)  Prepaid managed care plans shall submit encounter data
3413electronically in a format that complies with the Health
3414Insurance Portability and Accountability Act provisions for
3415electronic claims and in accordance with deadlines established
3416by the agency. Prepaid managed care plans must certify that the
3417data reported is accurate and complete.
3418     (b)  The agency is responsible for validating the data
3419submitted by the plans. The agency shall develop methods and
3420protocols for ongoing analysis of the encounter data that
3421adjusts for differences in characteristics of prepaid plan
3422enrollees to allow comparison of service utilization among plans
3423and against expected levels of use. The analysis shall be used
3424to identify possible cases of systemic underutilization or
3425denials of claims and inappropriate service utilization such as
3426higher-than-expected emergency department encounters. The
3427analysis shall provide periodic feedback to the plans and enable
3428the agency to establish corrective action plans when necessary.
3429One of the focus areas for the analysis shall be the use of
3430prescription drugs.
3431     (15)  The agency may establish a per-member, per-month
3432payment for Medicare Advantage Special Needs members that are
3433also eligible for Medicaid as a mechanism for meeting the
3434state's cost-sharing obligation. The agency may also develop a
3435per-member, per-month payment only for Medicaid-covered services
3436for which the state is responsible. The agency shall develop a
3437mechanism to ensure that such per-member, per-month payment
3438enhances the value to the state and enrolled members by limiting
3439cost sharing, enhances the scope of Medicare supplemental
3440benefits that are equal to or greater than Medicaid coverage for
3441select services, and improves care coordination.
3442     (16)  The agency shall establish, and managed care plans
3443shall use, a uniform method of accounting for and reporting
3444medical and nonmedical costs.
3445     (a)  Managed care plans shall submit financial data
3446electronically in a format that complies with the uniform
3447accounting procedures established by the agency. Managed care
3448plans must certify that the data reported is accurate and
3450     (b)  The agency is responsible for validating the financial
3451data submitted by the plans. The agency shall develop methods
3452and protocols for ongoing analysis of data that adjusts for
3453differences in characteristics of plan enrollees to allow
3454comparison among plans and against expected levels of
3455expenditures. The analysis shall be used to identify possible
3456cases of overspending on administrative costs or under spending
3457on medical services.
3458     (17)  The agency shall establish and maintain an
3459information system to make encounter data, financial data, and
3460other measures of plan performance to the public and any
3461interested party.
3462     (a)  Information submitted by the managed care plans shall
3463be available online as well as in other formats.
3464     (b)  Periodic agency reports shall be published that
3465include provide summary as well as plan specific measures of
3466financial performance and service utilization.
3467     (c)  Any release of the financial and encounter data
3468submitted by managed care plans shall ensure the confidentiality
3469of personal health information.
3470     (18)  The agency may, on a case-by-case basis, exempt a
3471recipient from mandatory enrollment in a managed care plan when
3472the recipient has a unique, time-limited disease or condition-
3473related circumstance and managed care enrollment will interfere
3474with ongoing care because the recipient's provider does not
3475participate in the managed care plans available in the
3476recipient's area.
3477     (19)  The agency shall contract with a single provider
3478service network to function as a managing entity for the
3479MediPass program in all counties with fewer than two prepaid
3480plans. The contractor shall be responsible for implementing
3481preauthorization procedures, case management programs, and
3482utilization management initiatives in order to improve care
3483coordination and patient outcomes while reducing costs. The
3484contractor may earn an administrative fee, if the fee is less
3485than any savings determined by the reconciliation process
3486pursuant to s. 409.912(4)(d)1. This subsection expires October
34871, 2014, or upon full implementation of the managed medical
3488assistance program, whichever is sooner.
3489     (20)  Subject to federal approval, the agency shall
3490contract with a single provider service network to function as a
3491third-party administrator and managing entity for the Medically
3492Needy program in all counties. The contractor shall provide care
3493coordination and utilization management in order to achieve more
3494cost-effective services for Medically Needy enrollees. To
3495facilitate the care management functions of the provider service
3496network, enrollment in the network shall be for a continuous 6-
3497month period or until the end of the contract between the
3498provider service network and the agency, whichever is sooner.
3499Beginning the second month after the determination of
3500eligibility, the contractor may collect a monthly premium from
3501each Medically Needy recipient provided the premium does not
3502exceed the enrollee's share of cost as determined by the
3503Department of Children and Family Services. The contractor must
3504provide a 90-day grace period before disenrolling a Medically
3505Needy recipient for failure to pay premiums. The contractor may
3506earn an administrative fee, if the fee is less than any savings
3507determined by the reconciliation process pursuant to s.
3508409.912(4)(d)1. Premium revenue collected from the recipients
3509shall be deducted from the contractor's earned savings. This
3510subsection expires October 1, 2014, or upon full implementation
3511of the managed medical assistance program, whichever is sooner.
3512     Section 22.  Subsection (15) of section 430.04, Florida
3513Statutes, is amended to read:
3514     430.04  Duties and responsibilities of the Department of
3515Elderly Affairs.-The Department of Elderly Affairs shall:
3516     (15)  Administer all Medicaid waivers and programs relating
3517to elders and their appropriations. The waivers include, but are
3518not limited to:
3519     (a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3520established in s. 430.502(7), (8), and (9).
3521     (a)(b)  The Assisted Living for the Frail Elderly Waiver.
3522     (b)(c)  The Aged and Disabled Adult Waiver.
3523     (c)(d)  The Adult Day Health Care Waiver.
3524     (d)(e)  The Consumer-Directed Care Plus Program as defined
3525in s. 409.221.
3526     (e)(f)  The Program of All-inclusive Care for the Elderly.
3527     (f)(g)  The Long-Term Care Community-Based Diversion Pilot
3528Project as described in s. 430.705.
3529     (g)(h)  The Channeling Services Waiver for Frail Elders.
3531The department shall develop a transition plan for recipients
3532receiving services in long-term care Medicaid waivers for elders
3533or disabled adults on the date eligible plans become available
3534in each recipient's region defined in s. 409.981(2) to enroll
3535those recipients in eligible plans. This subsection expires
3536October 1, 2014.
3537     Section 23.  Section 430.2053, Florida Statutes, is amended
3538to read:
3539     430.2053  Aging resource centers.-
3540     (1)  The department, in consultation with the Agency for
3541Health Care Administration and the Department of Children and
3542Family Services, shall develop pilot projects for aging resource
3543centers. By October 31, 2004, the department, in consultation
3544with the agency and the Department of Children and Family
3545Services, shall develop an implementation plan for aging
3546resource centers and submit the plan to the Governor, the
3547President of the Senate, and the Speaker of the House of
3548Representatives. The plan must include qualifications for
3549designation as a center, the functions to be performed by each
3550center, and a process for determining that a current area agency
3551on aging is ready to assume the functions of an aging resource
3553     (2)  Each area agency on aging shall develop, in
3554consultation with the existing community care for the elderly
3555lead agencies within their planning and service areas, a
3556proposal that describes the process the area agency on aging
3557intends to undertake to transition to an aging resource center
3558prior to July 1, 2005, and that describes the area agency's
3559compliance with the requirements of this section. The proposals
3560must be submitted to the department prior to December 31, 2004.
3561The department shall evaluate all proposals for readiness and,
3562prior to March 1, 2005, shall select three area agencies on
3563aging which meet the requirements of this section to begin the
3564transition to aging resource centers. Those area agencies on
3565aging which are not selected to begin the transition to aging
3566resource centers shall, in consultation with the department and
3567the existing community care for the elderly lead agencies within
3568their planning and service areas, amend their proposals as
3569necessary and resubmit them to the department prior to July 1,
35702005. The department may transition additional area agencies to
3571aging resource centers as it determines that area agencies are
3572in compliance with the requirements of this section.
3573     (3)  The Auditor General and the Office of Program Policy
3574Analysis and Government Accountability (OPPAGA) shall jointly
3575review and assess the department's process for determining an
3576area agency's readiness to transition to an aging resource
3578     (a)  The review must, at a minimum, address the
3579appropriateness of the department's criteria for selection of an
3580area agency to transition to an aging resource center, the
3581instruments applied, the degree to which the department
3582accurately determined each area agency's compliance with the
3583readiness criteria, the quality of the technical assistance
3584provided by the department to an area agency in correcting any
3585weaknesses identified in the readiness assessment, and the
3586degree to which each area agency overcame any identified
3588     (b)  Reports of these reviews must be submitted to the
3589appropriate substantive and appropriations committees in the
3590Senate and the House of Representatives on March 1 and September
35911 of each year until full transition to aging resource centers
3592has been accomplished statewide, except that the first report
3593must be submitted by February 1, 2005, and must address all
3594readiness activities undertaken through December 31, 2004. The
3595perspectives of all participants in this review process must be
3596included in each report.
3597     (2)(4)  The purposes of an aging resource center shall be:
3598     (a)  To provide Florida's elders and their families with a
3599locally focused, coordinated approach to integrating information
3600and referral for all available services for elders with the
3601eligibility determination entities for state and federally
3602funded long-term-care services.
3603     (b)  To provide for easier access to long-term-care
3604services by Florida's elders and their families by creating
3605multiple access points to the long-term-care network that flow
3606through one established entity with wide community recognition.
3607     (3)(5)  The duties of an aging resource center are to:
3608     (a)  Develop referral agreements with local community
3609service organizations, such as senior centers, existing elder
3610service providers, volunteer associations, and other similar
3611organizations, to better assist clients who do not need or do
3612not wish to enroll in programs funded by the department or the
3613agency. The referral agreements must also include a protocol,
3614developed and approved by the department, which provides
3615specific actions that an aging resource center and local
3616community service organizations must take when an elder or an
3617elder's representative seeking information on long-term-care
3618services contacts a local community service organization prior
3619to contacting the aging resource center. The protocol shall be
3620designed to ensure that elders and their families are able to
3621access information and services in the most efficient and least
3622cumbersome manner possible.
3623     (b)  Provide an initial screening of all clients who
3624request long-term-care services to determine whether the person
3625would be most appropriately served through any combination of
3626federally funded programs, state-funded programs, locally funded
3627or community volunteer programs, or private funding for
3629     (c)  Determine eligibility for the programs and services
3630listed in subsection (9) (11) for persons residing within the
3631geographic area served by the aging resource center and
3632determine a priority ranking for services which is based upon
3633the potential recipient's frailty level and likelihood of
3634institutional placement without such services.
3635     (d)  Manage the availability of financial resources for the
3636programs and services listed in subsection (9) (11) for persons
3637residing within the geographic area served by the aging resource
3639     (e)  When financial resources become available, refer a
3640client to the most appropriate entity to begin receiving
3641services. The aging resource center shall make referrals to lead
3642agencies for service provision that ensure that individuals who
3643are vulnerable adults in need of services pursuant to s.
3644415.104(3)(b), or who are victims of abuse, neglect, or
3645exploitation in need of immediate services to prevent further
3646harm and are referred by the adult protective services program,
3647are given primary consideration for receiving community-care-
3648for-the-elderly services in compliance with the requirements of
3649s. 430.205(5)(a) and that other referrals for services are in
3650compliance with s. 430.205(5)(b).
3651     (f)  Convene a work group to advise in the planning,
3652implementation, and evaluation of the aging resource center. The
3653work group shall be comprised of representatives of local
3654service providers, Alzheimer's Association chapters, housing
3655authorities, social service organizations, advocacy groups,
3656representatives of clients receiving services through the aging
3657resource center, and any other persons or groups as determined
3658by the department. The aging resource center, in consultation
3659with the work group, must develop annual program improvement
3660plans that shall be submitted to the department for
3661consideration. The department shall review each annual
3662improvement plan and make recommendations on how to implement
3663the components of the plan.
3664     (g)  Enhance the existing area agency on aging in each
3665planning and service area by integrating, either physically or
3666virtually, the staff and services of the area agency on aging
3667with the staff of the department's local CARES Medicaid nursing
3668home preadmission screening unit and a sufficient number of
3669staff from the Department of Children and Family Services'
3670Economic Self-Sufficiency Unit necessary to determine the
3671financial eligibility for all persons age 60 and older residing
3672within the area served by the aging resource center that are
3673seeking Medicaid services, Supplemental Security Income, and
3674food assistance.
3675     (h)  Assist clients who request long-term care services in
3676being evaluated for eligibility for enrollment in the Medicaid
3677long-term care managed care program as eligible plans become
3678available in each of the regions pursuant to s. 409.981(2).
3679     (i)  Provide enrollment and coverage information to
3680Medicaid managed long-term care enrollees as qualified plans
3681become available in each of the regions pursuant to s.
3683     (j)  Assist Medicaid recipients enrolled in the Medicaid
3684long-term care managed care program with informally resolving
3685grievances with a managed care network and assist Medicaid
3686recipients in accessing the managed care network's formal
3687grievance process as eligible plans become available in each of
3688the regions defined in s. 409.981(2).
3689     (4)(6)  The department shall select the entities to become
3690aging resource centers based on each entity's readiness and
3691ability to perform the duties listed in subsection (3) (5) and
3692the entity's:
3693     (a)  Expertise in the needs of each target population the
3694center proposes to serve and a thorough knowledge of the
3695providers that serve these populations.
3696     (b)  Strong connections to service providers, volunteer
3697agencies, and community institutions.
3698     (c)  Expertise in information and referral activities.
3699     (d)  Knowledge of long-term-care resources, including
3700resources designed to provide services in the least restrictive
3702     (e)  Financial solvency and stability.
3703     (f)  Ability to collect, monitor, and analyze data in a
3704timely and accurate manner, along with systems that meet the
3705department's standards.
3706     (g)  Commitment to adequate staffing by qualified personnel
3707to effectively perform all functions.
3708     (h)  Ability to meet all performance standards established
3709by the department.
3710     (5)(7)  The aging resource center shall have a governing
3711body which shall be the same entity described in s. 20.41(7),
3712and an executive director who may be the same person as
3713described in s. 20.41(7). The governing body shall annually
3714evaluate the performance of the executive director.
3715     (6)(8)  The aging resource center may not be a provider of
3716direct services other than information and referral services,
3717and screening.
3718     (7)(9)  The aging resource center must agree to allow the
3719department to review any financial information the department
3720determines is necessary for monitoring or reporting purposes,
3721including financial relationships.
3722     (8)(10)  The duties and responsibilities of the community
3723care for the elderly lead agencies within each area served by an
3724aging resource center shall be to:
3725     (a)  Develop strong community partnerships to maximize the
3726use of community resources for the purpose of assisting elders
3727to remain in their community settings for as long as it is
3728safely possible.
3729     (b)  Conduct comprehensive assessments of clients that have
3730been determined eligible and develop a care plan consistent with
3731established protocols that ensures that the unique needs of each
3732client are met.
3733     (9)(11)  The services to be administered through the aging
3734resource center shall include those funded by the following
3736     (a)  Community care for the elderly.
3737     (b)  Home care for the elderly.
3738     (c)  Contracted services.
3739     (d)  Alzheimer's disease initiative.
3740     (e)  Aged and disabled adult Medicaid waiver. This
3741paragraph expires October 1, 2013.
3742     (f)  Assisted living for the frail elderly Medicaid waiver.
3743This paragraph expires October 1, 2013.
3744     (g)  Older Americans Act.
3745     (10)(12)  The department shall, prior to designation of an
3746aging resource center, develop by rule operational and quality
3747assurance standards and outcome measures to ensure that clients
3748receiving services through all long-term-care programs
3749administered through an aging resource center are receiving the
3750appropriate care they require and that contractors and
3751subcontractors are adhering to the terms of their contracts and
3752are acting in the best interests of the clients they are
3753serving, consistent with the intent of the Legislature to reduce
3754the use of and cost of nursing home care. The department shall
3755by rule provide operating procedures for aging resource centers,
3756which shall include:
3757     (a)  Minimum standards for financial operation, including
3758audit procedures.
3759     (b)  Procedures for monitoring and sanctioning of service
3761     (c)  Minimum standards for technology utilized by the aging
3762resource center.
3763     (d)  Minimum staff requirements which shall ensure that the
3764aging resource center employs sufficient quality and quantity of
3765staff to adequately meet the needs of the elders residing within
3766the area served by the aging resource center.
3767     (e)  Minimum accessibility standards, including hours of
3769     (f)  Minimum oversight standards for the governing body of
3770the aging resource center to ensure its continuous involvement
3771in, and accountability for, all matters related to the
3772development, implementation, staffing, administration, and
3773operations of the aging resource center.
3774     (g)  Minimum education and experience requirements for
3775executive directors and other executive staff positions of aging
3776resource centers.
3777     (h)  Minimum requirements regarding any executive staff
3778positions that the aging resource center must employ and minimum
3779requirements that a candidate must meet in order to be eligible
3780for appointment to such positions.
3781     (11)(13)  In an area in which the department has designated
3782an area agency on aging as an aging resource center, the
3783department and the agency shall not make payments for the
3784services listed in subsection (9)      (11) and the Long-Term Care
3785Community Diversion Project for such persons who were not
3786screened and enrolled through the aging resource center. The
3787department shall cease making payments for recipients in
3788eligible plans as eligible plans become available in each of the
3789regions defined in s. 409.981(2).
3790     (12)(14)  Each aging resource center shall enter into a
3791memorandum of understanding with the department for
3792collaboration with the CARES unit staff. The memorandum of
3793understanding shall outline the staff person responsible for
3794each function and shall provide the staffing levels necessary to
3795carry out the functions of the aging resource center.
3796     (13)(15)  Each aging resource center shall enter into a
3797memorandum of understanding with the Department of Children and
3798Family Services for collaboration with the Economic Self-
3799Sufficiency Unit staff. The memorandum of understanding shall
3800outline which staff persons are responsible for which functions
3801and shall provide the staffing levels necessary to carry out the
3802functions of the aging resource center.
3803     (14)(16)  If any of the state activities described in this
3804section are outsourced, either in part or in whole, the contract
3805executing the outsourcing shall mandate that the contractor or
3806its subcontractors shall, either physically or virtually,
3807execute the provisions of the memorandum of understanding
3808instead of the state entity whose function the contractor or
3809subcontractor now performs.
3810     (15)(17)  In order to be eligible to begin transitioning to
3811an aging resource center, an area agency on aging board must
3812ensure that the area agency on aging which it oversees meets all
3813of the minimum requirements set by law and in rule.
3814     (18)  The department shall monitor the three initial
3815projects for aging resource centers and report on the progress
3816of those projects to the Governor, the President of the Senate,
3817and the Speaker of the House of Representatives by June 30,
38182005. The report must include an evaluation of the
3819implementation process.
3820     (16)(19)(a)  Once an aging resource center is operational,
3821the department, in consultation with the agency, may develop
3822capitation rates for any of the programs administered through
3823the aging resource center. Capitation rates for programs shall
3824be based on the historical cost experience of the state in
3825providing those same services to the population age 60 or older
3826residing within each area served by an aging resource center.
3827Each capitated rate may vary by geographic area as determined by
3828the department.
3829     (b)  The department and the agency may determine for each
3830area served by an aging resource center whether it is
3831appropriate, consistent with federal and state laws and
3832regulations, to develop and pay separate capitated rates for
3833each program administered through the aging resource center or
3834to develop and pay capitated rates for service packages which
3835include more than one program or service administered through
3836the aging resource center.
3837     (c)  Once capitation rates have been developed and
3838certified as actuarially sound, the department and the agency
3839may pay service providers the capitated rates for services when
3841     (d)  The department, in consultation with the agency, shall
3842annually reevaluate and recertify the capitation rates,
3843adjusting forward to account for inflation, programmatic
3845     (20)  The department, in consultation with the agency,
3846shall submit to the Governor, the President of the Senate, and
3847the Speaker of the House of Representatives, by December 1,
38482006, a report addressing the feasibility of administering the
3849following services through aging resource centers beginning July
38501, 2007:
3851     (a)  Medicaid nursing home services.
3852     (b)  Medicaid transportation services.
3853     (c)  Medicaid hospice care services.
3854     (d)  Medicaid intermediate care services.
3855     (e)  Medicaid prescribed drug services.
3856     (f)  Medicaid assistive care services.
3857     (g)  Any other long-term-care program or Medicaid service.
3858     (17)(21)  This section shall not be construed to allow an
3859aging resource center to restrict, manage, or impede the local
3860fundraising activities of service providers.
3861     Section 24.  Effective October 1, 2013, sections 430.701,
3862430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3863430.708, and 430.709, Florida Statutes, are repealed.
3864     Section 25.  Sections 409.9301, 409.942, 409.944, 409.945,
3865409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3866as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3867402.87, Florida Statutes, respectively.
3868     Section 26.  Paragraph (a) of subsection (1) of section
3869443.111, Florida Statutes, is amended to read:
3870     443.111  Payment of benefits.-
3871     (1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3872in accordance with rules adopted by the Agency for Workforce
3873Innovation, subject to the following requirements:
3874     (a)  Benefits are payable by mail or electronically.
3875Notwithstanding s. 402.82(4) s. 409.942(4), the agency may
3876develop a system for the payment of benefits by electronic funds
3877transfer, including, but not limited to, debit cards, electronic
3878payment cards, or any other means of electronic payment that the
3879agency deems to be commercially viable or cost-effective.
3880Commodities or services related to the development of such a
3881system shall be procured by competitive solicitation, unless
3882they are purchased from a state term contract pursuant to s.
3883287.056. The agency shall adopt rules necessary to administer
3884the system.
3885     Section 27.  Subsection (4) of section 641.386, Florida
3886Statutes, is amended to read:
3887     641.386  Agent licensing and appointment required;
3889     (4)  All agents and health maintenance organizations shall
3890comply with and be subject to the applicable provisions of ss.
3891641.309 and 409.912(20)(21), and all companies and entities
3892appointing agents shall comply with s. 626.451, when marketing
3893for any health maintenance organization licensed pursuant to
3894this part, including those organizations under contract with the
3895Agency for Health Care Administration to provide health care
3896services to Medicaid recipients or any private entity providing
3897health care services to Medicaid recipients pursuant to a
3898prepaid health plan contract with the Agency for Health Care
3900     Section 28.  Subsections (6) and (7) of section 766.118,
3901Florida Statutes, are renumbered as subsections (7) and (8),
3902respectively, and a new subsection (6) is added to that section,
3903to read:
3904     766.118  Determination of noneconomic damages.-
3907RECIPIENT.-Notwithstanding subsections (2), (3), and (5), with
3908respect to a cause of action for personal injury or wrongful
3909death arising from medical negligence of a practitioner
3910committed in the course of providing medical services and
3911medical care to a Medicaid recipient, regardless of the number
3912of such practitioner defendants providing the services and care,
3913noneconomic damages may not exceed $300,000 per claimant, unless
3914the claimant pleads and proves, by clear and convincing
3915evidence, that the practitioner acted in a wrongful manner. A
3916practitioner providing medical services and medical care to a
3917Medicaid recipient is not liable for more than $200,000 in
3918noneconomic damages, regardless of the number of claimants,
3919unless the claimant pleads and proves, by clear and convincing
3920evidence, that the practitioner acted in a wrongful manner. The
3921fact that a claimant proves that a practitioner acted in a
3922wrongful manner does not preclude the application of the
3923limitation on noneconomic damages prescribed elsewhere in this
3924section. For purposes of this subsection:
3925     (a)  The terms "medical services," "medical care," and
3926"Medicaid recipient" have the same meaning as provided in s.
3928     (b)  The term "practitioner," in addition to the meaning
3929prescribed in subsection (1), includes any hospital, ambulatory
3930surgical center, or mobile surgical facility as defined and
3931licensed under chapter 395.
3932     (c)  The term "wrongful manner" means in bad faith or with
3933malicious purpose or in a manner exhibiting wanton and willful
3934disregard of human rights, safety, or property, and shall be
3935construed in conformity with the standard set forth in s.
3937     Section 29.  The Agency for Health Care Administration
3938shall develop a plan for implementing a plan for medically needy
3939Medicaid enrollees pursuant to s. 409.975(8), Florida Statutes,
3940as created in HB 7107 or similar legislation that is adopted in
3941the same legislative session or an extension thereof and becomes
3942law, and shall immediately seek federal approval to implement
3943that subsection. The plan shall include a preliminary
3944calculation of actuarially sound rates and estimated fiscal
3946     Section 30.  The Agency for Health Care Administration
3947shall develop a reorganization plan for realignment of
3948administrative resources of the Medicaid program to respond to
3949changes in functional responsibilities and priorities necessary
3950for implementation of HB 7107 or similar legislation that is
3951adopted in the same legislative session or an extension thereof
3952and becomes law. The plan shall assess the agency's current
3953capabilities, identify shifts in staffing and other resources
3954necessary to strengthen procurement and contract monitoring
3955functions, and establish an implementation timeline. The plan
3956shall be submitted to the Governor, the Speaker of the House of
3957Representatives, and the President of the Senate by August 1,
3959     Section 31.  Subsection (1) of section 393.0662, Florida
3960Statutes, is amended to read:
3961     393.0662  Individual budgets for delivery of home and
3962community-based services; iBudget system established.-The
3963Legislature finds that improved financial management of the
3964existing home and community-based Medicaid waiver program is
3965necessary to avoid deficits that impede the provision of
3966services to individuals who are on the waiting list for
3967enrollment in the program. The Legislature further finds that
3968clients and their families should have greater flexibility to
3969choose the services that best allow them to live in their
3970community within the limits of an established budget. Therefore,
3971the Legislature intends that the agency, in consultation with
3972the Agency for Health Care Administration, develop and implement
3973a comprehensive redesign of the service delivery system using
3974individual budgets as the basis for allocating the funds
3975appropriated for the home and community-based services Medicaid
3976waiver program among eligible enrolled clients. The service
3977delivery system that uses individual budgets shall be called the
3978iBudget system.
3979     (1)  The agency shall establish an individual budget,
3980referred to as an iBudget, for each individual served by the
3981home and community-based services Medicaid waiver program. The
3982funds appropriated to the agency shall be allocated through the
3983iBudget system to eligible, Medicaid-enrolled clients. For the
3984iBudget system, eligible clients shall include individuals with
3985a diagnosis of Down syndrome or a developmental disability as
3986defined in s. 393.063. The iBudget system shall be designed to
3987provide for: enhanced client choice within a specified service
3988package; appropriate assessment strategies; an efficient
3989consumer budgeting and billing process that includes
3990reconciliation and monitoring components; a redefined role for
3991support coordinators that avoids potential conflicts of
3992interest; a flexible and streamlined service review process; and
3993a methodology and process that ensures the equitable allocation
3994of available funds to each client based on the client's level of
3995need, as determined by the variables in the allocation
3997     (a)  In developing each client's iBudget, the agency shall
3998use an allocation algorithm and methodology. The algorithm shall
3999use variables that have been determined by the agency to have a
4000statistically validated relationship to the client's level of
4001need for services provided through the home and community-based
4002services Medicaid waiver program. The algorithm and methodology
4003may consider individual characteristics, including, but not
4004limited to, a client's age and living situation, information
4005from a formal assessment instrument that the agency determines
4006is valid and reliable, and information from other assessment
4008     (b)  The allocation methodology shall provide the algorithm
4009that determines the amount of funds allocated to a client's
4010iBudget. The agency may approve an increase in the amount of
4011funds allocated, as determined by the algorithm, based on the
4012client having one or more of the following needs that cannot be
4013accommodated within the funding as determined by the algorithm
4014and having no other resources, supports, or services available
4015to meet the need:
4016     1.  An extraordinary need that would place the health and
4017safety of the client, the client's caregiver, or the public in
4018immediate, serious jeopardy unless the increase is approved. An
4019extraordinary need may include, but is not limited to:
4020     a.  A documented history of significant, potentially life-
4021threatening behaviors, such as recent attempts at suicide,
4022arson, nonconsensual sexual behavior, or self-injurious behavior
4023requiring medical attention;
4024     b.  A complex medical condition that requires active
4025intervention by a licensed nurse on an ongoing basis that cannot
4026be taught or delegated to a nonlicensed person;
4027     c.  A chronic comorbid condition. As used in this
4028subparagraph, the term "comorbid condition" means a medical
4029condition existing simultaneously but independently with another
4030medical condition in a patient; or
4031     d.  A need for total physical assistance with activities
4032such as eating, bathing, toileting, grooming, and personal
4035However, the presence of an extraordinary need alone does not
4036warrant an increase in the amount of funds allocated to a
4037client's iBudget as determined by the algorithm.
4038     2.  A significant need for one-time or temporary support or
4039services that, if not provided, would place the health and
4040safety of the client, the client's caregiver, or the public in
4041serious jeopardy, unless the increase is approved. A significant
4042need may include, but is not limited to, the provision of
4043environmental modifications, durable medical equipment, services
4044to address the temporary loss of support from a caregiver, or
4045special services or treatment for a serious temporary condition
4046when the service or treatment is expected to ameliorate the
4047underlying condition. As used in this subparagraph, the term
4048"temporary" means a period of fewer than 12 continuous months.
4049However, the presence of such significant need for one-time or
4050temporary supports or services alone does not warrant an
4051increase in the amount of funds allocated to a client's iBudget
4052as determined by the algorithm.
4053     3.  A significant increase in the need for services after
4054the beginning of the service plan year that would place the
4055health and safety of the client, the client's caregiver, or the
4056public in serious jeopardy because of substantial changes in the
4057client's circumstances, including, but not limited to, permanent
4058or long-term loss or incapacity of a caregiver, loss of services
4059authorized under the state Medicaid plan due to a change in age,
4060or a significant change in medical or functional status which
4061requires the provision of additional services on a permanent or
4062long-term basis that cannot be accommodated within the client's
4063current iBudget. As used in this subparagraph, the term "long-
4064term" means a period of 12 or more continuous months. However,
4065such significant increase in need for services of a permanent or
4066long-term nature alone does not warrant an increase in the
4067amount of funds allocated to a client's iBudget as determined by
4068the algorithm.
4070The agency shall reserve portions of the appropriation for the
4071home and community-based services Medicaid waiver program for
4072adjustments required pursuant to this paragraph and may use the
4073services of an independent actuary in determining the amount of
4074the portions to be reserved.
4075     (c)  A client's iBudget shall be the total of the amount
4076determined by the algorithm and any additional funding provided
4077pursuant to paragraph (b). A client's annual expenditures for
4078home and community-based services Medicaid waiver services may
4079not exceed the limits of his or her iBudget. The total of all
4080clients' projected annual iBudget expenditures may not exceed
4081the agency's appropriation for waiver services.
4082     Section 32.  Section 409.902, Florida Statutes, is amended
4083to read:
4084     409.902  Designated single state agency; payment
4085requirements; program title; release of medical records.-
4086     (1)  The Agency for Health Care Administration is
4087designated as the single state agency authorized to make
4088payments for medical assistance and related services under Title
4089XIX of the Social Security Act. These payments shall be made,
4090subject to any limitations or directions provided for in the
4091General Appropriations Act, only for services included in the
4092program, shall be made only on behalf of eligible individuals,
4093and shall be made only to qualified providers in accordance with
4094federal requirements for Title XIX of the Social Security Act
4095and the provisions of state law. This program of medical
4096assistance is designated the "Medicaid program." The Department
4097of Children and Family Services is responsible for Medicaid
4098eligibility determinations, including, but not limited to,
4099policy, rules, and the agreement with the Social Security
4100Administration for Medicaid eligibility determinations for
4101Supplemental Security Income recipients, as well as the actual
4102determination of eligibility. As a condition of Medicaid
4103eligibility, subject to federal approval, the Agency for Health
4104Care Administration and the Department of Children and Family
4105Services shall ensure that each recipient of Medicaid consents
4106to the release of her or his medical records to the Agency for
4107Health Care Administration and the Medicaid Fraud Control Unit
4108of the Department of Legal Affairs.
4109     (2)  Eligibility is restricted to United States citizens
4110and to lawfully admitted noncitizens who meet the criteria
4111provided in s. 414.095(3).
4112     (a)  Citizenship or immigration status must be verified.
4113For noncitizens, this includes verification of the validity of
4114documents with the United States Citizenship and Immigration
4115Services using the federal SAVE verification process.
4116     (b)  State funds may not be used to provide medical
4117services to individuals who do not meet the requirements of this
4118subsection unless the services are necessary to treat an
4119emergency medical condition or are for pregnant women. Such
4120services are authorized only to the extent provided under
4121federal law and in accordance with federal regulations as
4122provided in 42 C.F.R. s. 440.255.
4123     Section 33.  Subsection (22) is added to section 641.19,
4124Florida Statutes, to read:
4125     641.19  Definitions.-As used in this part, the term:
4126     (22)  "Provider service network" means a network authorized
4127under s. 409.912(4)(d), reimbursed on a prepaid basis, operated
4128by a health care provider or group of affiliated health care
4129providers, and which directly provides health care services
4130under a Medicare, Medicaid, or Healthy Kids contract.
4131     Section 34.  Section 641.2019, Florida Statutes, is created
4132to read:
4133     641.2019  Provider service network certificate of
4134authority.-A prepaid provider service network that applies for
4135and obtains a health care provider certificate pursuant to part
4136III of this chapter, meets the surplus requirements of s.
4137641.225, and meets all other applicable requirements of this
4138part may obtain a certificate of authority under s. 641.21. A
4139certified provider service network has the same rights and
4140responsibilities as a health maintenance organization certified
4141under this part.
4142     Section 35.  Subsection (2) of section 641.2261, Florida
4143Statutes, is amended to read:
4144     641.2261  Application of solvency requirements to provider-
4145sponsored organizations and Medicaid provider service networks.-
4146     (2)  Except for a provider service network seeking to
4147obtain a certificate of authority under s. 641.2019, the
4148solvency requirements in 42 C.F.R. s. 422.350, subpart H, and
4149the solvency requirements established in approved federal
4150waivers pursuant to chapter 409 apply to a Medicaid provider
4151service network rather than the solvency requirements of this
4153     Section 36.  If any provision of this act or its
4154application to any person or circumstance is held invalid, the
4155invalidity does not affect other provisions or applications of
4156the act which can be given effect without the invalid provision
4157or application, and to this end the provisions of this act are
4159     Section 37.  Except as otherwise expressly provided in this
4160act, this act shall take effect July 1, 2011, if HB 7107 or
4161similar legislation is adopted in the same legislative session
4162or an extension thereof and becomes law.

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