Florida Senate - 2020                                    SB 7046
       By the Committee on Governmental Oversight and Accountability
       585-02629-20                                          20207046__
    1                        A bill to be entitled                      
    2         An act relating to the state group insurance program;
    3         amending s. 110.123, F.S.; revising the definition of
    4         “full-time state employees” to conform to changes made
    5         by the act; authorizing persons eligible to
    6         participate in the program to elect membership with
    7         certain health maintenance organization plans;
    8         requiring at least one health maintenance organization
    9         plan be made available to each enrollee residing in
   10         the state; deleting provisions providing for the
   11         establishment of health maintenance organization plan
   12         regions by Department of Management Services rule;
   13         deleting the requirement that health plans be offered
   14         in specified benefit levels; deleting obsolete
   15         language regarding eligibility for participation in
   16         the program for other-personal-services employees;
   17         establishing regions for health maintenance
   18         organizations for specified purposes; providing for
   19         construction; creating s. 110.12305, F.S.; defining
   20         terms; prohibiting specified fraudulent acts in
   21         connection with the program, including the submission
   22         of fraudulent insurance claims, making false
   23         statements in claims, and the acceptance of certain
   24         payments; providing criminal penalties; specifying
   25         that the repayment, or attempted repayments, of any
   26         unlawful payments does not constitute a defense or a
   27         ground for dismissal for a violation of the act;
   28         specifying which property is deemed to be paid for by
   29         the program; specifying application of the business
   30         records hearsay exception to certain records in the
   31         custody of the department or a contracted vendor;
   32         specifying factors that establish an inference that a
   33         person had knowledge of a false statement or false
   34         representation regarding a claim; prohibiting the sale
   35         or purchase of a legend drug paid for by the program;
   36         providing criminal penalties; prohibiting a person
   37         from knowingly making or causing to be made, or
   38         attempting or conspiring to make, any false statement
   39         or representation in order to obtain goods or services
   40         from the program; providing criminal penalties;
   41         providing immunity for certain persons who provide
   42         information regarding provider fraud to governmental
   43         entities; specifying the scope of such immunity;
   44         defining the term “fraudulent acts”; requiring the
   45         department to publicize certain terms of the Florida
   46         False Claims Act to state employees and the public;
   47         creating s. 110.12306, F.S.; defining a term;
   48         requiring the Division of State Group Insurance to
   49         establish an anti-fraud unit for certain purposes by a
   50         specified date; authorizing the division to contract
   51         with other parties to perform certain anti-fraud
   52         measures; requiring the division to adopt an anti
   53         fraud plan and designate at least one employee to
   54         implement anti-fraud measures; amending s. 110.12315,
   55         F.S.; modifying requirements for identifying a
   56         medically necessary drug excluded from the formulary
   57         on a prescription; prohibiting the department or its
   58         pharmacy benefit manager from substituting its
   59         judgment over the judgment of a prescriber in
   60         determining whether a drug excluded from the formulary
   61         is medically necessary; requiring the department or
   62         its pharmacy benefit manager to take specified action
   63         regarding formulary management; removing a limitation
   64         for the annual maximum amount for coverage for
   65         medically necessary prescription and nonprescription
   66         enteral formulas and amino-acid-based elemental
   67         formulas for home use; requiring the department to
   68         ensure that the prescription drug program receives
   69         certain benefits, and to perform annual audits of such
   70         benefits; amending s. 110.131, F.S.; conforming a
   71         cross-reference; providing an effective date.
   73  Be It Enacted by the Legislature of the State of Florida:
   75         Section 1. Paragraph (c) of subsection (2), paragraphs (h),
   76  (j), and (k) of subsection (3), and paragraphs (c) and (d) of
   77  subsection (13) of section 110.123, Florida Statutes, are
   78  amended, and subsection (14) is added to that section, to read:
   79         110.123 State group insurance program.—
   80         (2) DEFINITIONS.—As used in ss. 110.123-110.1239, the term:
   81         (c) “Full-time state employees” means employees of all
   82  branches or agencies of state government holding salaried
   83  positions who are paid by state warrant or from agency funds and
   84  who work or are expected to work an average of at least 30 or
   85  more hours per week; employees paid from regular salary
   86  appropriations for 8 months’ employment, including university
   87  personnel on academic contracts; and employees paid from other
   88  personal-services (OPS) funds who are reasonably expected to
   89  work an average of at least 30 hours or more per week or have
   90  worked an average of at least 30 hours or more per week during
   91  the employee’s measurement period as described in subparagraphs
   92  1. and 2. The term includes all full-time employees of the state
   93  universities. The term does not include seasonal workers who are
   94  paid from OPS funds.
   95         1. For persons hired before April 1, 2013, the term
   96  includes any person paid from OPS funds who:
   97         a. Has worked an average of at least 30 hours or more per
   98  week during the initial measurement period from April 1, 2013,
   99  through September 30, 2013; or
  100         b. Has worked an average of at least 30 hours or more per
  101  week during a subsequent measurement period.
  102         2. For persons hired after April 1, 2013, the term includes
  103  any person paid from OPS funds who:
  104         a. Is reasonably expected to work an average of at least 30
  105  hours or more per week; or
  106         b. Has worked an average of at least 30 hours or more per
  107  week during the person’s measurement period.
  109         (h)1. A person eligible to participate in the state group
  110  insurance program may be authorized by rules adopted by the
  111  department, in lieu of participating in the state group health
  112  insurance plan, may to exercise an option to elect membership in
  113  a health maintenance organization plan which is under contract
  114  with the state in accordance with criteria established by this
  115  section and by said rules adopted by the department. The offer
  116  of optional membership in a health maintenance organization plan
  117  permitted by this paragraph may be limited or conditioned by
  118  rule as may be necessary to meet the requirements of state and
  119  federal laws.
  120         2. The department shall contract with health maintenance
  121  organizations seeking to participate in the state group
  122  insurance program through a request for proposal or other
  123  procurement process, as developed by the Department of
  124  Management Services and determined to be appropriate.
  125         a. The department shall establish a schedule of minimum
  126  benefits for health maintenance organization coverage, and that
  127  schedule shall include: physician services; inpatient and
  128  outpatient hospital services; emergency medical services,
  129  including out-of-area emergency coverage; diagnostic laboratory
  130  and diagnostic and therapeutic radiologic services; mental
  131  health, alcohol, and chemical dependency treatment services
  132  meeting the minimum requirements of state and federal law;
  133  skilled nursing facilities and services; prescription drugs;
  134  age-based and gender-based wellness benefits; and other benefits
  135  as may be required by the department. Additional services may be
  136  provided subject to the contract between the department and the
  137  HMO. As used in this paragraph, the term “age-based and gender
  138  based wellness benefits” includes aerobic exercise, education in
  139  alcohol and substance abuse prevention, blood cholesterol
  140  screening, health risk appraisals, blood pressure screening and
  141  education, nutrition education, program planning, safety belt
  142  education, smoking cessation, stress management, weight
  143  management, and women’s health education.
  144         b. The department may establish uniform deductibles,
  145  copayments, coverage tiers, or coinsurance schedules for all
  146  participating HMO plans.
  147         c. The department may require detailed information from
  148  each health maintenance organization participating in the
  149  procurement process, including information pertaining to
  150  organizational status, experience in providing prepaid health
  151  benefits, accessibility of services, financial stability of the
  152  plan, quality of management services, accreditation status,
  153  quality of medical services, network access and adequacy,
  154  performance measurement, ability to meet the department’s
  155  reporting requirements, and the actuarial basis of the proposed
  156  rates and other data determined by the director to be necessary
  157  for the evaluation and selection of health maintenance
  158  organization plans and negotiation of appropriate rates for
  159  these plans. Upon receipt of proposals by health maintenance
  160  organization plans and the evaluation of those proposals, the
  161  department may enter into negotiations with all of the plans or
  162  a subset of the plans, as the department determines appropriate.
  163  The department may negotiate regional or statewide contracts
  164  with health maintenance organization plans. Such plans must be
  165  cost-effective and must offer high value to enrollees.
  166         d. The department may limit the number of HMOs that it
  167  contracts with in each region based on the nature of the bids
  168  the department receives, the number of state employees in the
  169  region, or any unique characteristics of the region. At least
  170  one HMO plan must be available to each enrollee residing in the
  171  state The department shall establish the regions throughout the
  172  state by rule. The department must submit the rule to the
  173  President of the Senate and the Speaker of the House of
  174  Representatives for ratification no later than 30 days before
  175  the 2020 Regular Session of the Legislature. The rule may not
  176  take effect until it is ratified by the Legislature.
  177         e. All persons participating in the state group insurance
  178  program may be required to contribute towards a total state
  179  group health premium that may vary depending upon the plan,
  180  coverage level, and coverage tier selected by the enrollee and
  181  the level of state contribution authorized by the Legislature.
  182         3. The department is authorized to negotiate and to
  183  contract with specialty psychiatric hospitals for mental health
  184  benefits, on a regional basis, for alcohol, drug abuse, and
  185  mental and nervous disorders. The department may establish,
  186  subject to the approval of the Legislature pursuant to
  187  subsection (5), any such regional plan upon completion of an
  188  actuarial study to determine any impact on plan benefits and
  189  premiums.
  190         4. In addition to contracting pursuant to subparagraph 2.,
  191  the department may enter into contract with any HMO to
  192  participate in the state group insurance program which:
  193         a. Serves greater than 5,000 recipients on a prepaid basis
  194  under the Medicaid program;
  195         b. Does not currently meet the 25-percent non-Medicare/non
  196  Medicaid enrollment composition requirement established by the
  197  Department of Health excluding participants enrolled in the
  198  state group insurance program;
  199         c. Meets the minimum benefit package and copayments and
  200  deductibles contained in sub-subparagraphs 2.a. and b.;
  201         d. Is willing to participate in the state group insurance
  202  program at a cost of premiums that is not greater than 95
  203  percent of the cost of HMO premiums accepted by the department
  204  in each service area; and
  205         e. Meets the minimum surplus requirements of s. 641.225.
  207  The department is authorized to contract with HMOs that meet the
  208  requirements of sub-subparagraphs a.-d. prior to the open
  209  enrollment period for state employees. The department is not
  210  required to renew the contract with the HMOs as set forth in
  211  this paragraph more than twice. Thereafter, the HMOs shall be
  212  eligible to participate in the state group insurance program
  213  only through the request for proposal or invitation to negotiate
  214  process described in subparagraph 2.
  215         5. All enrollees in a state group health insurance plan, a
  216  TRICARE supplemental insurance plan, or any health maintenance
  217  organization plan have the option of changing to any other
  218  health plan that is offered by the state within any open
  219  enrollment period designated by the department. Open enrollment
  220  shall be held at least once each calendar year.
  221         6. When a contract between a treating provider and the
  222  state-contracted health maintenance organization is terminated
  223  for any reason other than for cause, each party shall allow any
  224  enrollee for whom treatment was active to continue coverage and
  225  care when medically necessary, through completion of treatment
  226  of a condition for which the enrollee was receiving care at the
  227  time of the termination, until the enrollee selects another
  228  treating provider, or until the next open enrollment period
  229  offered, whichever is longer, but no longer than 6 months after
  230  termination of the contract. Each party to the terminated
  231  contract shall allow an enrollee who has initiated a course of
  232  prenatal care, regardless of the trimester in which care was
  233  initiated, to continue care and coverage until completion of
  234  postpartum care. This does not prevent a provider from refusing
  235  to continue to provide care to an enrollee who is abusive,
  236  noncompliant, or in arrears in payments for services provided.
  237  For care continued under this subparagraph, the program and the
  238  provider shall continue to be bound by the terms of the
  239  terminated contract. Changes made within 30 days before
  240  termination of a contract are effective only if agreed to by
  241  both parties.
  242         7. Any HMO participating in the state group insurance
  243  program shall submit health care utilization and cost data to
  244  the department, in such form and in such manner as the
  245  department shall require, as a condition of participating in the
  246  program. The department shall enter into negotiations with its
  247  contracting HMOs to determine the nature and scope of the data
  248  submission and the final requirements, format, penalties
  249  associated with noncompliance, and timetables for submission.
  250  These determinations shall be adopted by rule.
  251         8. The department may establish and direct, with respect to
  252  collective bargaining issues, a comprehensive package of
  253  insurance benefits that may include supplemental health and life
  254  coverage, dental care, long-term care, vision care, and other
  255  benefits it determines necessary to enable state employees to
  256  select from among benefit options that best suit their
  257  individual and family needs. Beginning with the 2018 plan year,
  258  the package of benefits may also include products and services
  259  described in s. 110.12303.
  260         a. Based upon a desired benefit package, the department
  261  shall issue a request for proposal or invitation to negotiate
  262  for providers interested in participating in the state group
  263  insurance program, and the department shall issue a request for
  264  proposal or invitation to negotiate for providers interested in
  265  participating in the non-health-related components of the state
  266  group insurance program. Upon receipt of all proposals, the
  267  department may enter into contract negotiations with providers
  268  submitting bids or negotiate a specially designed benefit
  269  package. Providers offering or providing supplemental coverage
  270  as of May 30, 1991, which qualify for pretax benefit treatment
  271  pursuant to s. 125 of the Internal Revenue Code of 1986, with
  272  5,500 or more state employees currently enrolled may be included
  273  by the department in the supplemental insurance benefit plan
  274  established by the department without participating in a request
  275  for proposal, submitting bids, negotiating contracts, or
  276  negotiating a specially designed benefit package. These
  277  contracts shall provide state employees with the most cost
  278  effective and comprehensive coverage available; however, except
  279  as provided in subparagraph (f)3., no state or agency funds
  280  shall be contributed toward the cost of any part of the premium
  281  of such supplemental benefit plans. With respect to dental
  282  coverage, the division shall include in any solicitation or
  283  contract for any state group dental program made after July 1,
  284  2001, a comprehensive indemnity dental plan option which offers
  285  enrollees a completely unrestricted choice of dentists. If a
  286  dental plan is endorsed, or in some manner recognized as the
  287  preferred product, such plan shall include a comprehensive
  288  indemnity dental plan option which provides enrollees with a
  289  completely unrestricted choice of dentists.
  290         b. Pursuant to the applicable provisions of s. 110.161, and
  291  s. 125 of the Internal Revenue Code of 1986, the department
  292  shall enroll in the pretax benefit program those state employees
  293  who voluntarily elect coverage in any of the supplemental
  294  insurance benefit plans as provided by sub-subparagraph a.
  295         c. Nothing herein contained shall be construed to prohibit
  296  insurance providers from continuing to provide or offer
  297  supplemental benefit coverage to state employees as provided
  298  under existing agency plans.
  299         (j) For the 2020 plan year and each plan year thereafter,
  300  health plans shall be offered in the following benefit levels:
  301         1. Platinum level, which shall have an actuarial value of
  302  at least 90 percent.
  303         2. Gold level, which shall have an actuarial value of at
  304  least 80 percent.
  305         3. Silver level, which shall have an actuarial value of at
  306  least 70 percent.
  307         4. Bronze level, which shall have an actuarial value of at
  308  least 60 percent.
  309         (k) In consultation with the independent benefits
  310  consultant described in s. 110.12304, the department shall
  311  develop a plan for implementation of the benefit levels
  312  described in paragraph (j). The plan shall be submitted to the
  313  Governor, the President of the Senate, and the Speaker of the
  314  House of Representatives by January 1, 2019, and include
  315  recommendations for:
  316         1. Employer and employee contribution policies.
  317         2. Steps necessary for maintaining or improving total
  318  employee compensation levels when the transition is initiated.
  319         3. An education strategy to inform employees of the
  320  additional choices available in the state group insurance
  321  program.
  323  This paragraph expires July 1, 2019.
  325         (c) The initial measurement period used to determine
  326  whether an employee hired before April 1, 2013, and paid from
  327  OPS funds is a full-time employee described in subparagraph
  328  (2)(c)1. is the 6-month period from April 1, 2013, through
  329  September 30, 2013.
  330         (d) All other measurement periods used to determine whether
  331  an employee paid from OPS funds is a full-time employee
  332  described in paragraph (2)(c) must be for 12 consecutive months.
  334         (a) The following regions are established for purposes of
  335  the department entering into contracts with HMOs to provide
  336  services on a regional basis on or after January 1, 2023,
  337  pursuant to paragraph (3)(h):
  338         1. Region 1 consists of Bay, Calhoun, Escambia, Gulf,
  339  Holmes, Jackson, Okaloosa, Santa Rosa, Walton, and Washington
  340  Counties.
  341         2. Region 2 consists of Franklin, Gadsden, Jefferson, Leon,
  342  Liberty, Madison, Taylor, and Wakulla Counties.
  343         3. Region 3 consists of Alachua, Bradford, Columbia, Dixie,
  344  Gilchrist, Hamilton, Lafayette, Levy, Marion, Suwannee, and
  345  Union Counties.
  346         4. Region 4 consists of Baker, Clay, Duval, Flagler,
  347  Nassau, Putnam, St. Johns, and Volusia Counties.
  348         5. Region 5 consists of Brevard, Indian River, Lake,
  349  Orange, Osceola, and Seminole Counties.
  350         6. Region 6 consists of Citrus, DeSoto, Hardee, Hernando,
  351  Highlands, Hillsborough, Manatee, Pasco, Pinellas, Polk,
  352  Sarasota, and Sumter Counties.
  353         7. Region 7 consists of Martin, Okeechobee, Palm Beach, and
  354  St. Lucie Counties.
  355         8. Region 8 consists of Charlotte, Collier, Glades, Hendry,
  356  and Lee Counties.
  357         9. Region 9 consists of Broward, Miami-Dade, and Monroe
  358  Counties.
  359         (b) The establishment of these regions does not limit the
  360  department’s authority to contract for HMO services on a
  361  statewide basis.
  362         Section 2. Section 110.12305, Florida Statutes, is created
  363  to read:
  364         110.12305 Provider fraud.—
  365         (1) As used in this section, the term:
  366         (a) “Item or service” includes:
  367         1. Any particular item, device, medical supply, or service
  368  claimed to have been provided to a health plan member and listed
  369  in an itemized claim for payment; or
  370         2. In the case of a claim based on costs, any entry in the
  371  cost report, books of account, or other documents supporting
  372  such claim.
  373         (b) “Knowingly” means that the act was done voluntarily and
  374  intentionally and not because of mistake or accident. As used in
  375  this section, the term also includes the word “willfully” or
  376  “willful,” which means that an act was committed voluntarily and
  377  purposely, with the specific intent to do something prohibited
  378  by law, and that the act was committed with bad purpose, either
  379  to disobey or disregard the law.
  380         (c) “Prescription drug” means any drug, including, but not
  381  limited to, finished dosage forms or active ingredients that are
  382  subject to, defined in, or described in s. 503(b) of the Federal
  383  Food, Drug, and Cosmetic Act or in s. 465.003(8), s.
  384  499.003(17), s. 499.007(13), or s. 499.82(10).
  385         (d) “Provider” means any person providing health care
  386  services or prescription drugs and supplies funded by the
  387  program.
  388         (e) “Value” means the amount billed to the program for the
  389  property dispensed or the market value of a legend drug or goods
  390  or services at the time and place of the offense. If the market
  391  value cannot be determined, the term means the replacement cost
  392  of the legend drug or goods or services within a reasonable time
  393  after the offense.
  394         (2)(a) A person may not:
  395         1. Knowingly make, cause to be made, or aid and abet in the
  396  making of any false statement or false representation of a
  397  material fact, by commission or omission, in any claim submitted
  398  to the department or its contracted vendors for payment.
  399         2. Knowingly make, cause to be made, or aid and abet in the
  400  making of a claim for items or services that are not authorized
  401  to be reimbursed by the program.
  402         3. Knowingly charge, solicit, accept, or receive anything
  403  of value, other than an authorized copayment from a health plan
  404  member, from any source in addition to the amount legally
  405  payable for an item or service provided to a health plan member
  406  under the program or knowingly fail to credit the department or
  407  its contracted vendors for any payment received from a third
  408  party source.
  409         4. Knowingly solicit, offer, pay, or receive any
  410  remuneration, including any kickback, bribe, or rebate, directly
  411  or indirectly, overtly or covertly, in cash or in kind, in
  412  return for referring an individual to a person for the
  413  furnishing or arranging of any item or service for which payment
  414  may be made, in whole or in part, under the program, or in
  415  return for obtaining, purchasing, leasing, ordering, or
  416  arranging for or recommending, obtaining, purchasing, leasing,
  417  or ordering any goods, facility, item, or service for which
  418  payment may be made, in whole or in part, under the program.
  419         (b)1. A person who violates this subsection and receives or
  420  endeavors to receive anything of value of:
  421         a. Ten thousand dollars or less commits a felony of the
  422  third degree, punishable as provided in s. 775.082, s. 775.083,
  423  or s. 775.084.
  424         b. More than $10,000, but less than $50,000, commits a
  425  felony of the second degree, punishable as provided in s.
  426  775.082, s. 775.083, or s. 775.084.
  427         c. Fifty thousand dollars or more commits a felony of the
  428  first degree, punishable as provided in s. 775.082, s. 775.083,
  429  or s. 775.084.
  430         2. The value of separate funds, goods, or services that a
  431  person received or attempted to receive pursuant to a scheme or
  432  course of conduct may be aggregated in determining the degree of
  433  the offense.
  434         3. In addition to the sentence authorized by law, a person
  435  who is convicted of a violation of this subsection shall pay a
  436  fine in an amount equal to five times the pecuniary gain
  437  unlawfully received or the loss incurred by the program or
  438  contracted vendor, whichever amount is greater.
  439         (3) The repayment of any payments wrongfully obtained, or
  440  the offer or endeavor to repay funds wrongfully obtained, does
  441  not constitute a defense to or a ground for dismissal of
  442  criminal charges brought under this section.
  443         (4) Property paid for by the program includes all property
  444  furnished or intended to be furnished to any health plan member
  445  of benefits under the program, regardless of whether
  446  reimbursement is ever actually made by the program.
  447         (5) All records in the custody of the department or its
  448  contracted vendors which relate to provider fraud are business
  449  records within the meaning of s. 90.803(6).
  450         (6) Proof that a claim was submitted to the department or
  451  its contracted vendors which contained a false statement or a
  452  false representation of a material fact, by commission or
  453  omission, unless satisfactorily explained, gives rise to an
  454  inference that the person whose signature appears as the
  455  provider’s authorizing signature on the claim form, or whose
  456  signature appears on an electronic claim submission agreement
  457  submitted for claims made to the contracted vendor by electronic
  458  means, had knowledge of the false statement or false
  459  representation. This subsection applies whether the signature
  460  appears on the claim form or the electronic claim submission
  461  agreement by means of handwriting, typewriting, facsimile
  462  signature stamp, computer impulse, initials, or otherwise.
  463         (7) Any person who knowingly sells, who knowingly attempts
  464  or conspires to sell, or who knowingly causes any other person
  465  to sell or attempt or conspire to sell a legend drug that was
  466  paid for by the program commits a felony.
  467         (a) If the value of the legend drug involved is less than
  468  $20,000, the crime is a felony of the third degree, punishable
  469  as provided in s. 775.082, s. 775.083, or s. 775.084.
  470         (b) If the value of the legend drug involved is $20,000 or
  471  more but less than $100,000, the crime is a felony of the second
  472  degree, punishable as provided in s. 775.082, s. 775.083, or s.
  473  775.084.
  474         (c) If the value of the legend drug involved is $100,000 or
  475  more, the crime is a felony of the first degree, punishable as
  476  provided in s. 775.082, s. 775.083, or s. 775.084.
  477         (8) Any person who knowingly purchases, or who knowingly
  478  attempts or conspires to purchase, a legend drug that was paid
  479  for by the program and intended for use by another person
  480  commits a felony.
  481         (a) If the value of the legend drug is less than $20,000,
  482  the crime is a felony of the third degree, punishable as
  483  provided in s. 775.082, s. 775.083, or s. 775.084.
  484         (b) If the value of the legend drug is $20,000 or more but
  485  less than $100,000, the crime is a felony of the second degree,
  486  punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
  487         (c) If the value of the legend drug is $100,000 or more,
  488  the crime is a felony of the first degree, punishable as
  489  provided in s. 775.082, s. 775.083, or s. 775.084.
  490         (9) Any person who knowingly makes or knowingly causes to
  491  be made, or who attempts or conspires to make, any false
  492  statement or representation to any person for the purpose of
  493  obtaining goods or services from the program commits a felony.
  494         (a) If the value of the goods or services is less than
  495  $20,000, the crime is a felony of the third degree, punishable
  496  as provided in s. 775.082, s. 775.083, or s. 775.084.
  497         (b) If the value of the goods or services is $20,000 or
  498  more but less than $100,000, the crime is a felony of the second
  499  degree, punishable as provided in s. 775.082, s. 775.083, or s.
  500  775.084.
  501         (c) If the value of the goods or services involved is
  502  $100,000 or more, the crime is a felony of the first degree,
  503  punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
  505  The value of individual items of the legend drugs or goods or
  506  services involved in distinct transactions committed during a
  507  single scheme or course of conduct, whether involving a single
  508  person or several persons, may be aggregated when determining
  509  the punishment for the offense.
  510         (10) A person who provides the state, any state agency, or
  511  any political subdivision of the state or an agency thereof with
  512  information about fraud or suspected fraudulent acts by a
  513  provider is immune from civil liability for libel, slander, or
  514  any other relevant tort for providing such information unless
  515  the person acted with knowledge that the information was false
  516  or with reckless disregard for the truth or falsity of the
  517  information. Such immunity extends to reports of fraudulent acts
  518  or suspected fraudulent acts conveyed to or from the department
  519  in any manner, including any forum and with any audience as
  520  directed by the department, and includes all discussions
  521  subsequent to the report and subsequent inquiries from the
  522  department, unless the person acted with knowledge that the
  523  information was false or with reckless disregard for the truth
  524  or falsity of the information. As used in this subsection, the
  525  term “fraudulent acts” includes actual or suspected fraud and
  526  abuse, insurance fraud, or licensure fraud, including any fraud
  527  related matters that a provider or health plan is required to
  528  report to the department or a law enforcement agency.
  529         (11) The department must publicize to state employees and
  530  the public the ability of persons to bring a civil action under
  531  the provisions of the Florida False Claims Act and the potential
  532  for the persons bringing a civil action under the act to obtain
  533  a monetary award.
  534         Section 3. Section 110.12306, Florida Statutes, is created
  535  to read:
  536         110.12306 Anti-fraud investigative units.—
  537         (1) As used in this section, the term designated anti
  538  fraud unit” means a distinct unit within the division which is
  539  made up of employees whose principal responsibilities are the
  540  investigation and disposition of claims and who are also
  541  assigned investigation of fraud.
  542         (2) By December 31, 2020, the division:
  543         (a)1. Shall establish and maintain a designated anti-fraud
  544  unit to investigate and report possible fraudulent insurance
  545  acts by insureds, persons making claims for services against the
  546  State Employees Health Insurance Trust Fund, or vendors under
  547  contract with the division.
  548         2. May contract with others to investigate and report
  549  possible fraudulent insurance acts by insureds, persons making
  550  claims for services against the State Employees Health Insurance
  551  Trust Fund, or vendors under contract with the division.
  552         (b) Shall adopt an anti-fraud plan.
  553         (c) Shall designate at least one employee with the primary
  554  responsibility of implementing the requirements of this section.
  555         Section 4. Paragraph (a) of subsection (9) and subsection
  556  (10) of section 110.12315, Florida Statutes, are amended, and
  557  subsection (11) is added to that section, to read:
  558         110.12315 Prescription drug program.—The state employees’
  559  prescription drug program is established. This program shall be
  560  administered by the Department of Management Services, according
  561  to the terms and conditions of the plan as established by the
  562  relevant provisions of the annual General Appropriations Act and
  563  implementing legislation, subject to the following conditions:
  564         (9)(a)1. Beginning with the 2020 plan year, the department
  565  must implement formulary management for prescription drugs and
  566  supplies. Such management practices must require prescription
  567  drugs to be subject to formulary inclusion or exclusion but may
  568  not restrict access to the most clinically appropriate,
  569  clinically effective, and lowest net-cost prescription drugs and
  570  supplies. Drugs excluded from the formulary must be available
  571  for inclusion if a physician, an advanced practice registered
  572  nurse, or a physician assistant prescribing a pharmaceutical
  573  clearly states on the prescription, or otherwise in the manner
  574  specified in s. 465.025(2), that the excluded drug is medically
  575  necessary. The department or its pharmacy benefit manager may
  576  not substitute its judgment over the judgment of the prescriber
  577  of a prescription drug as to whether the drug is medically
  578  necessary.
  579         2. The department or its pharmacy benefit manager must
  580  ensure that:
  581         a. The condition for which the patient is being treated is
  582  covered under the program;
  583         b.The prescribed drug is approved by the Federal Drug
  584  Administration or supported in the compendia of current
  585  literature for the treatment of the patient’s condition; and
  586         c. The prescribed dosage falls within the Federal Drug
  587  Administration approved labeling or within dosing guidelines
  588  found in the compendia of current literature as treatment for
  589  the patient’s condition.
  590         3. If the prescription drug or supply is not included on
  591  the formulary but is prescribed as medically necessary for the
  592  treatment of the patient, the department or its pharmacy benefit
  593  manager must inquire of the prescribing authority as to whether:
  594         a. The prescribing authority has considered alternative
  595  prescription drugs and supplies that are included on the
  596  formulary;
  597         b. The patient has tried and had inadequate treatment
  598  response or intolerance to alternative prescription drugs that
  599  are included on the formulary; and
  600         c. The patient has a contraindication to the alternative
  601  prescription drugs that are included on the formulary.
  603  Such inquiries must be made as soon as practicable but no later
  604  than the next business day after the pharmacist received the
  605  prescription.
  606         4. Prescription drugs and supplies first made available in
  607  the marketplace after January 1, 2020, may not be covered by the
  608  prescription drug program until specifically included in the
  609  list of covered prescription drugs and supplies.
  610         (10) In addition to the comprehensive package of health
  611  insurance and other benefits required or authorized to be
  612  included in the state group insurance program, the program must
  613  provide coverage for medically necessary prescription and
  614  nonprescription enteral formulas and amino-acid-based elemental
  615  formulas for home use, regardless of the method of delivery or
  616  intake, which are ordered or prescribed by a physician. As used
  617  in this subsection, the term “medically necessary” means the
  618  formula to be covered represents the only medically appropriate
  619  source of nutrition for a patient. Such coverage may not exceed
  620  an amount of $20,000 annually for any insured individual.
  621         (11) The department must ensure that the prescription drug
  622  program receives the benefits of all discounts, rebates, and
  623  other fees associated with the prescription drugs and supplies
  624  provided through the program. The department shall annually
  625  audit the amounts of discounts, rebates, and other fees received
  626  by the department or its pharmacy benefit manager for the
  627  prescription drugs and supplies provided through the program.
  628         Section 5. Subsection (5) of section 110.131, Florida
  629  Statutes, is amended to read:
  630         110.131 Other-personal-services employment.—
  631         (5) Beginning January 1, 2014, an other-personal-services
  632  (OPS) employee who has worked an average of at least 30 or more
  633  hours per week during the measurement period described in s.
  634  110.123(13)(c) s. 110.123(13)(c) or (d), or who is reasonably
  635  expected to work an average of at least 30 or more hours per
  636  week following his or her employment, is eligible to participate
  637  in the state group insurance program as provided under s.
  638  110.123.
  639         Section 6. This act shall take effect July 1, 2020.