HB 7109

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 393.0661, F.S.;
3	requiring the Agency for Persons with Disabilities to
4	establish a transition plan for current Medicaid
5	recipients of home and community-based services under
6	certain circumstances; providing for expiration of the
7	section on a specified date; amending s. 393.0662, F.S.;
8	requiring the Agency for Persons with Disabilities to
9	complete the transition for current Medicaid recipients of
10	home and community-based services to the iBudget system by
11	a specified date; requiring the Agency for Persons with
12	Disabilities to develop a transition plan for current
13	Medicaid recipients of home and community-based services
14	to managed care plans; providing for expiration of the
15	section on a specified date; amending s. 408.040, F.S.;
16	providing for suspension of certain conditions precedent
17	to the issuance of a certificate of need for a nursing
18	home, effective on a specified date; amending s. 408.0435,
19	F.S.; extending the certificate-of-need moratorium for
20	additional community nursing home beds; designating ss.
21	409.016-409.803, F.S., as pt. I of ch. 409, F.S., and
22	entitling the part "Social and Economic Assistance";
23	designating ss. 409.810-409.821, F.S., as pt. II of ch.
24	409, F.S., and entitling the part "Kidcare"; designating
25	ss. 409.901-409.9205, F.S., as part III of ch. 409, F.S.,
26	and entitling the part "Medicaid"; amending s. 409.905,
27	F.S.; requiring the Agency for Health Care Administration
28	to set reimbursements rates for hospitals that provide
29	Medicaid services based on allowable-cost reporting from
30	the hospitals; providing the methodology for the rate
31	calculation and adjustments; requiring the rates to be
32	subject to certain limits or ceilings; providing that
33	exemptions to the limits or ceilings may be provided in
34	the General Appropriations Act; deleting provisions
35	relating to agency adjustments to a hospital's inpatient
36	per diem rate; directing the agency to develop a plan to
37	convert inpatient hospital rates to a prospective payment
38	system that categorizes each case into diagnosis-related
39	groups; requiring a report to the Governor and
40	Legislature; amending s. 409.911, F.S.; providing for
41	expiration of the Medicaid Low-Income Pool Council;
42	amending s. 409.912, F.S.; providing payment requirements
43	for provider service networks; providing for the
44	expiration of various provisions relating to agency
45	contracts and agreements with certain entities on
46	specified dates to conform to the reorganization of
47	Medicaid managed care; requiring the agency to contract on
48	a prepaid or fixed-sum basis with certain prepaid dental
49	health plans; eliminating obsolete provisions and updating
50	provisions, to conform; amending ss. 409.91195 and
51	409.91196, F.S.; conforming cross-references; repealing s.
52	409.91207, F.S., relating to the medical home pilot
53	project; amending s. 409.91211, F.S.; conforming cross-
54	references; providing for future repeal of s. 409.91211,
55	F.S., relating to the Medicaid managed care pilot program;
56	amending s. 409.9122, F.S.; providing for the expiration
57	of provisions relating to mandatory enrollment in a
58	Medicaid managed care plan or MediPass on specified dates
59	to conform to the reorganization of Medicaid managed care;
60	eliminating obsolete provisions; requiring the agency to
61	develop a process to enable any recipient with access to
62	employer-sponsored coverage to opt out of eligible plans
63	in the Medicaid program; requiring the agency, contingent
64	on federal approval, to enable recipients with access to
65	other coverage or related products that provide access to
66	specified health care services to opt out of eligible
67	plans in the Medicaid program; requiring the agency to
68	maintain and operate the Medicaid Encounter Data System;
69	requiring the agency to conduct a review of encounter data
70	and publish the results of the review before adjusting
71	rates for prepaid plans; authorizing the agency to
72	establish a designated payment for specified Medicare
73	Advantage Special Needs members; authorizing the agency to
74	develop a designated payment for Medicaid-only covered
75	services for which the state is responsible; requiring the
76	agency to establish, and managed care plans to use, a
77	uniform method of accounting for and reporting medical and
78	nonmedical costs; authorizing the agency to create
79	exceptions to mandatory enrollment in managed care under
80	specified circumstances; requiring the agency to contract
81	with a provider service network to function as a third-
82	party administrator and managing entity for the MediPass
83	program; providing contract provisions; providing for the
84	expiration of such contract requirements on a specified
85	date; amending s. 430.04, F.S.; eliminating obsolete
86	provisions; requiring the Department of Elderly Affairs to
87	develop a transition plan for specified elders and
88	disabled adults receiving long-term care Medicaid services
89	when eligible plans become available; providing for
90	expiration of the plan; amending s. 430.2053, F.S.;
91	eliminating obsolete provisions; providing additional
92	duties of aging resource centers; providing an additional
93	exception to direct services that may not be provided by
94	an aging resource center; providing an expiration date for
95	certain services administered through aging resource
96	centers; providing for the cessation of specified payments
97	by the department as eligible plans become available;
98	providing for a memorandum of understanding between the
99	agency and aging resource centers under certain
100	circumstances; eliminating provisions requiring reports;
101	repealing s. 430.701, F.S., relating to legislative
102	findings and intent and approval for action relating to
103	provider enrollment levels; repealing s. 430.702, F.S.,
104	relating to the Long-Term Care Community Diversion Pilot
105	Project Act; repealing s. 430.703, F.S., relating to
106	definitions; repealing s. 430.7031, F.S., relating to the
107	nursing home transition program; repealing s. 430.704,
108	F.S., relating to evaluation of long-term care through the
109	pilot projects; repealing s. 430.705, F.S., relating to
110	implementation of long-term care community diversion pilot
111	projects; repealing s. 430.706, F.S., relating to quality
112	of care; repealing s. 430.707, F.S., relating to
113	contracts; repealing s. 430.708, F.S., relating to
114	certificate of need; repealing s. 430.709, F.S., relating
115	to reports and evaluations; renumbering ss. 409.9301,
116	409.942, 409.944, 409.945, 409.946, 409.953, and 409.9531,
117	F.S., as ss. 402.81, 402.82, 402.83, 402.84, 402.85,
118	402.86, and 402.87, F.S., respectively; amending ss.
119	443.111 and 641.386, F.S.; conforming cross-references;
120	directing the agency to develop a plan to implement the
121	enrollment of the medically needy into managed care;
122	providing effective dates and a contingent effective date.
123
124	Be It Enacted by the Legislature of the State of Florida:
125
126	Section 1.  Section 393.0661, Florida Statutes, is amended
127	to read:
128	393.0661  Home and community-based services delivery
129	system; comprehensive redesign.-The Legislature finds that the
130	home and community-based services delivery system for persons
131	with developmental disabilities and the availability of
132	appropriated funds are two of the critical elements in making
133	services available. Therefore, it is the intent of the
134	Legislature that the Agency for Persons with Disabilities shall
135	develop and implement a comprehensive redesign of the system.
136	(1)  The redesign of the home and community-based services
137	system shall include, at a minimum, all actions necessary to
138	achieve an appropriate rate structure, client choice within a
139	specified service package, appropriate assessment strategies, an
140	efficient billing process that contains reconciliation and
141	monitoring components, and a redefined role for support
142	coordinators that avoids potential conflicts of interest and
143	ensures that family/client budgets are linked to levels of need.
144	(a)  The agency shall use an assessment instrument that the
145	agency deems to be reliable and valid, including, but not
146	limited to, the Department of Children and Family Services'
147	Individual Cost Guidelines or the agency's Questionnaire for
148	Situational Information. The agency may contract with an
149	external vendor or may use support coordinators to complete
150	client assessments if it develops sufficient safeguards and
151	training to ensure ongoing inter-rater reliability.
152	(b)  The agency, with the concurrence of the Agency for
153	Health Care Administration, may contract for the determination
154	of medical necessity and establishment of individual budgets.
155	(2)  A provider of services rendered to persons with
156	developmental disabilities pursuant to a federally approved
157	waiver shall be reimbursed according to a rate methodology based
158	upon an analysis of the expenditure history and prospective
159	costs of providers participating in the waiver program, or under
160	any other methodology developed by the Agency for Health Care
161	Administration, in consultation with the Agency for Persons with
162	Disabilities, and approved by the Federal Government in
163	accordance with the waiver.
164	(3)  The Agency for Health Care Administration, in
165	consultation with the agency, shall seek federal approval and
166	implement a four-tiered waiver system to serve eligible clients
167	through the developmental disabilities and family and supported
168	living waivers. The agency shall assign all clients receiving
169	services through the developmental disabilities waiver to a tier
170	based on the Department of Children and Family Services'
171	Individual Cost Guidelines, the agency's Questionnaire for
172	Situational Information, or another such assessment instrument
173	deemed to be valid and reliable by the agency; client
174	characteristics, including, but not limited to, age; and other
175	appropriate assessment methods.
176	(a)  Tier one is limited to clients who have service needs
177	that cannot be met in tier two, three, or four for intensive
178	medical or adaptive needs and that are essential for avoiding
179	institutionalization, or who possess behavioral problems that
180	are exceptional in intensity, duration, or frequency and present
181	a substantial risk of harm to themselves or others. Total annual
182	expenditures under tier one may not exceed $150,000 per client
183	each year, provided that expenditures for clients in tier one
184	with a documented medical necessity requiring intensive
185	behavioral residential habilitation services, intensive
186	behavioral residential habilitation services with medical needs,
187	or special medical home care, as provided in the Developmental
188	Disabilities Waiver Services Coverage and Limitations Handbook,
189	are not subject to the $150,000 limit on annual expenditures.
190	(b)  Tier two is limited to clients whose service needs
191	include a licensed residential facility and who are authorized
192	to receive a moderate level of support for standard residential
193	habilitation services or a minimal level of support for behavior
194	focus residential habilitation services, or clients in supported
195	living who receive more than 6 hours a day of in-home support
196	services. Total annual expenditures under tier two may not
197	exceed $53,625 per client each year.
198	(c)  Tier three includes, but is not limited to, clients
199	requiring residential placements, clients in independent or
200	supported living situations, and clients who live in their
201	family home. Total annual expenditures under tier three may not
202	exceed $34,125 per client each year.
203	(d)  Tier four includes individuals who were enrolled in
204	the family and supported living waiver on July 1, 2007, who
205	shall be assigned to this tier without the assessments required
206	by this section. Tier four also includes, but is not limited to,
207	clients in independent or supported living situations and
208	clients who live in their family home. Total annual expenditures
209	under tier four may not exceed $14,422 per client each year.
210	(e)  The Agency for Health Care Administration shall also
211	seek federal approval to provide a consumer-directed option for
212	persons with developmental disabilities which corresponds to the
213	funding levels in each of the waiver tiers. The agency shall
214	implement the four-tiered waiver system beginning with tiers
215	one, three, and four and followed by tier two. The agency and
216	the Agency for Health Care Administration may adopt rules
217	necessary to administer this subsection.
218	(f)  The agency shall seek federal waivers and amend
219	contracts as necessary to make changes to services defined in
220	federal waiver programs administered by the agency as follows:
221	1.  Supported living coaching services may not exceed 20
222	hours per month for persons who also receive in-home support
223	services.
224	2.  Limited support coordination services is the only type
225	of support coordination service that may be provided to persons
226	under the age of 18 who live in the family home.
227	3.  Personal care assistance services are limited to 180
228	hours per calendar month and may not include rate modifiers.
229	Additional hours may be authorized for persons who have
230	intensive physical, medical, or adaptive needs if such hours are
231	essential for avoiding institutionalization.
232	4.  Residential habilitation services are limited to 8
233	hours per day. Additional hours may be authorized for persons
234	who have intensive medical or adaptive needs and if such hours
235	are essential for avoiding institutionalization, or for persons
236	who possess behavioral problems that are exceptional in
237	intensity, duration, or frequency and present a substantial risk
238	of harming themselves or others. This restriction shall be in
239	effect until the four-tiered waiver system is fully implemented.
240	5.  Chore services, nonresidential support services, and
241	homemaker services are eliminated. The agency shall expand the
242	definition of in-home support services to allow the service
243	provider to include activities previously provided in these
244	eliminated services.
245	6.  Massage therapy, medication review, and psychological
246	assessment services are eliminated.
247	7.  The agency shall conduct supplemental cost plan reviews
248	to verify the medical necessity of authorized services for plans
249	that have increased by more than 8 percent during either of the
250	2 preceding fiscal years.
251	8.  The agency shall implement a consolidated residential
252	habilitation rate structure to increase savings to the state
253	through a more cost-effective payment method and establish
254	uniform rates for intensive behavioral residential habilitation
255	services.
256	9.  Pending federal approval, the agency may extend current
257	support plans for clients receiving services under Medicaid
258	waivers for 1 year beginning July 1, 2007, or from the date
259	approved, whichever is later. Clients who have a substantial
260	change in circumstances which threatens their health and safety
261	may be reassessed during this year in order to determine the
262	necessity for a change in their support plan.
263	10.  The agency shall develop a plan to eliminate
264	redundancies and duplications between in-home support services,
265	companion services, personal care services, and supported living
266	coaching by limiting or consolidating such services.
267	11.  The agency shall develop a plan to reduce the
268	intensity and frequency of supported employment services to
269	clients in stable employment situations who have a documented
270	history of at least 3 years' employment with the same company or
271	in the same industry.
272	(4)  The geographic differential for Miami-Dade, Broward,
273	and Palm Beach Counties for residential habilitation services
274	shall be 7.5 percent.
275	(5)  The geographic differential for Monroe County for
276	residential habilitation services shall be 20 percent.
277	(6)  Effective January 1, 2010, and except as otherwise
278	provided in this section, a client served by the home and
279	community-based services waiver or the family and supported
280	living waiver funded through the agency shall have his or her
281	cost plan adjusted to reflect the amount of expenditures for the
282	previous state fiscal year plus 5 percent if such amount is less
283	than the client's existing cost plan. The agency shall use
284	actual paid claims for services provided during the previous
285	fiscal year that are submitted by October 31 to calculate the
286	revised cost plan amount. If the client was not served for the
287	entire previous state fiscal year or there was any single change
288	in the cost plan amount of more than 5 percent during the
289	previous state fiscal year, the agency shall set the cost plan
290	amount at an estimated annualized expenditure amount plus 5
291	percent. The agency shall estimate the annualized expenditure
292	amount by calculating the average of monthly expenditures,
293	beginning in the fourth month after the client enrolled,
294	interrupted services are resumed, or the cost plan was changed
295	by more than 5 percent and ending on August 31, 2009, and
296	multiplying the average by 12. In order to determine whether a
297	client was not served for the entire year, the agency shall
298	include any interruption of a waiver-funded service or services
299	lasting at least 18 days. If at least 3 months of actual
300	expenditure data are not available to estimate annualized
301	expenditures, the agency may not rebase a cost plan pursuant to
302	this subsection. The agency may not rebase the cost plan of any
303	client who experiences a significant change in recipient
304	condition or circumstance which results in a change of more than
305	5 percent to his or her cost plan between July 1 and the date
306	that a rebased cost plan would take effect pursuant to this
307	subsection.
308	(7)  Nothing in this section or in any administrative rule
309	shall be construed to prevent or limit the Agency for Health
310	Care Administration, in consultation with the Agency for Persons
311	with Disabilities, from adjusting fees, reimbursement rates,
312	lengths of stay, number of visits, or number of services, or
313	from limiting enrollment, or making any other adjustment
314	necessary to comply with the availability of moneys and any
315	limitations or directions provided for in the General
316	Appropriations Act.
317	(8)  The Agency for Persons with Disabilities shall submit
318	quarterly status reports to the Executive Office of the
319	Governor, the chair of the Senate Ways and Means Committee or
320	its successor, and the chair of the House Fiscal Council or its
321	successor regarding the financial status of home and community-
322	based services, including the number of enrolled individuals who
323	are receiving services through one or more programs; the number
324	of individuals who have requested services who are not enrolled
325	but who are receiving services through one or more programs,
326	with a description indicating the programs from which the
327	individual is receiving services; the number of individuals who
328	have refused an offer of services but who choose to remain on
329	the list of individuals waiting for services; the number of
330	individuals who have requested services but who are receiving no
331	services; a frequency distribution indicating the length of time
332	individuals have been waiting for services; and information
333	concerning the actual and projected costs compared to the amount
334	of the appropriation available to the program and any projected
335	surpluses or deficits. If at any time an analysis by the agency,
336	in consultation with the Agency for Health Care Administration,
337	indicates that the cost of services is expected to exceed the
338	amount appropriated, the agency shall submit a plan in
339	accordance with subsection (7) to the Executive Office of the
340	Governor, the chair of the Senate Ways and Means Committee or
341	its successor, and the chair of the House Fiscal Council or its
342	successor to remain within the amount appropriated. The agency
343	shall work with the Agency for Health Care Administration to
344	implement the plan so as to remain within the appropriation.
345	(9)  The agency shall develop a transition plan for
346	recipients who are receiving services in one of the four waiver
347	tiers at the time eligible managed care plans are available in
348	each recipient's region as defined in s. 409.989 to enroll those
349	recipients in eligible plans.
350	(10)  This section expires October 1, 2016.
351	Section 2.  Section 393.0662, Florida Statutes, is amended
352	to read:
353	393.0662  Individual budgets for delivery of home and
354	community-based services; iBudget system established.-The
355	Legislature finds that improved financial management of the
356	existing home and community-based Medicaid waiver program is
357	necessary to avoid deficits that impede the provision of
358	services to individuals who are on the waiting list for
359	enrollment in the program. The Legislature further finds that
360	clients and their families should have greater flexibility to
361	choose the services that best allow them to live in their
362	community within the limits of an established budget. Therefore,
363	the Legislature intends that the agency, in consultation with
364	the Agency for Health Care Administration, develop and implement
365	a comprehensive redesign of the service delivery system using
366	individual budgets as the basis for allocating the funds
367	appropriated for the home and community-based services Medicaid
368	waiver program among eligible enrolled clients. The service
369	delivery system that uses individual budgets shall be called the
370	iBudget system.
371	(1)  The agency shall establish an individual budget,
372	referred to as an iBudget, for each individual served by the
373	home and community-based services Medicaid waiver program. The
374	funds appropriated to the agency shall be allocated through the
375	iBudget system to eligible, Medicaid-enrolled clients. The
376	iBudget system shall be designed to provide for: enhanced client
377	choice within a specified service package; appropriate
378	assessment strategies; an efficient consumer budgeting and
379	billing process that includes reconciliation and monitoring
380	components; a redefined role for support coordinators that
381	avoids potential conflicts of interest; a flexible and
382	streamlined service review process; and a methodology and
383	process that ensures the equitable allocation of available funds
384	to each client based on the client's level of need, as
385	determined by the variables in the allocation algorithm.
386	(a)  In developing each client's iBudget, the agency shall
387	use an allocation algorithm and methodology. The algorithm shall
388	use variables that have been determined by the agency to have a
389	statistically validated relationship to the client's level of
390	need for services provided through the home and community-based
391	services Medicaid waiver program. The algorithm and methodology
392	may consider individual characteristics, including, but not
393	limited to, a client's age and living situation, information
394	from a formal assessment instrument that the agency determines
395	is valid and reliable, and information from other assessment
396	processes.
397	(b)  The allocation methodology shall provide the algorithm
398	that determines the amount of funds allocated to a client's
399	iBudget. The agency may approve an increase in the amount of
400	funds allocated, as determined by the algorithm, based on the
401	client having one or more of the following needs that cannot be
402	accommodated within the funding as determined by the algorithm
403	and having no other resources, supports, or services available
404	to meet the need:
405	1.  An extraordinary need that would place the health and
406	safety of the client, the client's caregiver, or the public in
407	immediate, serious jeopardy unless the increase is approved. An
408	extraordinary need may include, but is not limited to:
409	a.  A documented history of significant, potentially life-
410	threatening behaviors, such as recent attempts at suicide,
411	arson, nonconsensual sexual behavior, or self-injurious behavior
412	requiring medical attention;
413	b.  A complex medical condition that requires active
414	intervention by a licensed nurse on an ongoing basis that cannot
415	be taught or delegated to a nonlicensed person;
416	c.  A chronic comorbid condition. As used in this
417	subparagraph, the term "comorbid condition" means a medical
418	condition existing simultaneously but independently with another
419	medical condition in a patient; or
420	d.  A need for total physical assistance with activities
421	such as eating, bathing, toileting, grooming, and personal
422	hygiene.
423
424	However, the presence of an extraordinary need alone does not
425	warrant an increase in the amount of funds allocated to a
426	client's iBudget as determined by the algorithm.
427	2.  A significant need for one-time or temporary support or
428	services that, if not provided, would place the health and
429	safety of the client, the client's caregiver, or the public in
430	serious jeopardy, unless the increase is approved. A significant
431	need may include, but is not limited to, the provision of
432	environmental modifications, durable medical equipment, services
433	to address the temporary loss of support from a caregiver, or
434	special services or treatment for a serious temporary condition
435	when the service or treatment is expected to ameliorate the
436	underlying condition. As used in this subparagraph, the term
437	"temporary" means a period of fewer than 12 continuous months.
438	However, the presence of such significant need for one-time or
439	temporary supports or services alone does not warrant an
440	increase in the amount of funds allocated to a client's iBudget
441	as determined by the algorithm.
442	3.  A significant increase in the need for services after
443	the beginning of the service plan year that would place the
444	health and safety of the client, the client's caregiver, or the
445	public in serious jeopardy because of substantial changes in the
446	client's circumstances, including, but not limited to, permanent
447	or long-term loss or incapacity of a caregiver, loss of services
448	authorized under the state Medicaid plan due to a change in age,
449	or a significant change in medical or functional status which
450	requires the provision of additional services on a permanent or
451	long-term basis that cannot be accommodated within the client's
452	current iBudget. As used in this subparagraph, the term "long-
453	term" means a period of 12 or more continuous months. However,
454	such significant increase in need for services of a permanent or
455	long-term nature alone does not warrant an increase in the
456	amount of funds allocated to a client's iBudget as determined by
457	the algorithm.
458
459	The agency shall reserve portions of the appropriation for the
460	home and community-based services Medicaid waiver program for
461	adjustments required pursuant to this paragraph and may use the
462	services of an independent actuary in determining the amount of
463	the portions to be reserved.
464	(c)  A client's iBudget shall be the total of the amount
465	determined by the algorithm and any additional funding provided
466	pursuant to paragraph (b). A client's annual expenditures for
467	home and community-based services Medicaid waiver services may
468	not exceed the limits of his or her iBudget. The total of all
469	clients' projected annual iBudget expenditures may not exceed
470	the agency's appropriation for waiver services.
471	(2)  The Agency for Health Care Administration, in
472	consultation with the agency, shall seek federal approval to
473	amend current waivers, request a new waiver, and amend contracts
474	as necessary to implement the iBudget system to serve eligible,
475	enrolled clients through the home and community-based services
476	Medicaid waiver program and the Consumer-Directed Care Plus
477	Program.
478	(3)  The agency shall transition all eligible, enrolled
479	clients to the iBudget system. The agency may gradually phase in
480	the iBudget system and must complete the phase in by January 1,
481	2015.
482	(a)  While the agency phases in the iBudget system, the
483	agency may continue to serve eligible, enrolled clients under
484	the four-tiered waiver system established under s. 393.065 while
485	those clients await transitioning to the iBudget system.
486	(b)  The agency shall design the phase-in process to ensure
487	that a client does not experience more than one-half of any
488	expected overall increase or decrease to his or her existing
489	annualized cost plan during the first year that the client is
490	provided an iBudget due solely to the transition to the iBudget
491	system.
492	(4)  A client must use all available services authorized
493	under the state Medicaid plan, school-based services, private
494	insurance and other benefits, and any other resources that may
495	be available to the client before using funds from his or her
496	iBudget to pay for support and services.
497	(5)  The service limitations in s. 393.0661(3)(f)1., 2.,
498	and 3. do not apply to the iBudget system.
499	(6)  Rates for any or all services established under rules
500	of the Agency for Health Care Administration shall be designated
501	as the maximum rather than a fixed amount for individuals who
502	receive an iBudget, except for services specifically identified
503	in those rules that the agency determines are not appropriate
504	for negotiation, which may include, but are not limited to,
505	residential habilitation services.
506	(7)  The agency shall ensure that clients and caregivers
507	have access to training and education to inform them about the
508	iBudget system and enhance their ability for self-direction.
509	Such training shall be offered in a variety of formats and at a
510	minimum shall address the policies and processes of the iBudget
511	system; the roles and responsibilities of consumers, caregivers,
512	waiver support coordinators, providers, and the agency;
513	information available to help the client make decisions
514	regarding the iBudget system; and examples of support and
515	resources available in the community.
516	(8)  The agency shall collect data to evaluate the
517	implementation and outcomes of the iBudget system.
518	(9)  The agency and the Agency for Health Care
519	Administration may adopt rules specifying the allocation
520	algorithm and methodology; criteria and processes for clients to
521	access reserved funds for extraordinary needs, temporarily or
522	permanently changed needs, and one-time needs; and processes and
523	requirements for selection and review of services, development
524	of support and cost plans, and management of the iBudget system
525	as needed to administer this section.
526	(10)  The agency shall develop a transition plan for
527	recipients who are receiving services through the iBudget system
528	at the time eligible managed care plans are available in each
529	recipient's region defined in s. 409.989 to enroll those
530	recipients in eligible plans.
531	(11)  This section expires October 1, 2016.
532	Section 3.  Paragraph (e) of subsection (1) of section
533	408.040, Florida Statutes, is redesignated as paragraph (d), and
534	paragraph (b) and present paragraph (d) of that subsection are
535	amended to read:
536	408.040  Conditions and monitoring.-
537	(1)
538	(b)  The agency may consider, in addition to the other
539	criteria specified in s. 408.035, a statement of intent by the
540	applicant that a specified percentage of the annual patient days
541	at the facility will be utilized by patients eligible for care
542	under Title XIX of the Social Security Act. Any certificate of
543	need issued to a nursing home in reliance upon an applicant's
544	statements that a specified percentage of annual patient days
545	will be utilized by residents eligible for care under Title XIX
546	of the Social Security Act must include a statement that such
547	certification is a condition of issuance of the certificate of
548	need. The certificate-of-need program shall notify the Medicaid
549	program office and the Department of Elderly Affairs when it
550	imposes conditions as authorized in this paragraph in an area in
551	which a community diversion pilot project is implemented.
552	Effective July 1, 2012, the agency may not consider, or impose
553	conditions or sanctions related to, patient day utilization by
554	patients eligible for care under Title XIX the Social Security
555	Act in making certificate-of-need determinations for nursing
556	homes.
557	(d)  If a nursing home is located in a county in which a
558	long-term care community diversion pilot project has been
559	implemented under s. 430.705 or in a county in which an
560	integrated, fixed-payment delivery program for Medicaid
561	recipients who are 60 years of age or older or dually eligible
562	for Medicare and Medicaid has been implemented under s.
563	409.912(5), the nursing home may request a reduction in the
564	percentage of annual patient days used by residents who are
565	eligible for care under Title XIX of the Social Security Act,
566	which is a condition of the nursing home's certificate of need.
567	The agency shall automatically grant the nursing home's request
568	if the reduction is not more than 15 percent of the nursing
569	home's annual Medicaid-patient-days condition. A nursing home
570	may submit only one request every 2 years for an automatic
571	reduction. A requesting nursing home must notify the agency in
572	writing at least 60 days in advance of its intent to reduce its
573	annual Medicaid-patient-days condition by not more than 15
574	percent. The agency must acknowledge the request in writing and
575	must change its records to reflect the revised certificate-of-
576	need condition. This paragraph expires June 30, 2011.
577	Section 4.  Subsection (1) of section 408.0435, Florida
578	Statutes, is amended to read:
579	408.0435  Moratorium on nursing home certificates of need.-
580	(1)  Notwithstanding the establishment of need as provided
581	for in this chapter, a certificate of need for additional
582	community nursing home beds may not be approved by the agency
583	until Medicaid managed care is implemented statewide pursuant to
584	ss. 409.961-409.992 or October 1, 2016, whichever is earlier
585	July 1, 2011.
586	Section 5.  Sections 409.016 through 409.803, Florida
587	Statutes, are designated as part I of chapter 409, Florida
588	Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
589	Section 6.  Sections 409.810 through 409.821, Florida
590	Statutes, are designated as part II of chapter 409, Florida
591	Statutes, and entitled "KIDCARE."
592	Section 7.  Sections 409.901 through 409.9205, Florida
593	Statutes, are designated as part III of chapter 409, Florida
594	Statutes, and entitled "MEDICAID."
595	Section 8.  Paragraph (c) of subsection (5) of section
596	409.905, Florida Statutes, is amended, and paragraph (g) is
597	added that subsection, to read:
598	409.905  Mandatory Medicaid services.-The agency may make
599	payments for the following services, which are required of the
600	state by Title XIX of the Social Security Act, furnished by
601	Medicaid providers to recipients who are determined to be
602	eligible on the dates on which the services were provided. Any
603	service under this section shall be provided only when medically
604	necessary and in accordance with state and federal law.
605	Mandatory services rendered by providers in mobile units to
606	Medicaid recipients may be restricted by the agency. Nothing in
607	this section shall be construed to prevent or limit the agency
608	from adjusting fees, reimbursement rates, lengths of stay,
609	number of visits, number of services, or any other adjustments
610	necessary to comply with the availability of moneys and any
611	limitations or directions provided for in the General
612	Appropriations Act or chapter 216.
613	(5)  HOSPITAL INPATIENT SERVICES.-The agency shall pay for
614	all covered services provided for the medical care and treatment
615	of a recipient who is admitted as an inpatient by a licensed
616	physician or dentist to a hospital licensed under part I of
617	chapter 395. However, the agency shall limit the payment for
618	inpatient hospital services for a Medicaid recipient 21 years of
619	age or older to 45 days or the number of days necessary to
620	comply with the General Appropriations Act.
621	(c)  The agency shall implement a methodology for
622	establishing base reimbursement rates for each hospital based on
623	allowable costs, as defined by the agency. Rates shall be
624	calculated annually and take effect July 1 of each year based on
625	the most recent complete and accurate cost report submitted by
626	each hospital. Adjustments may not be made to the rates after
627	September 30 of the state fiscal year in which the rate takes
628	effect. Errors in cost reporting or calculation of rates
629	discovered after September 30 must be reconciled in a subsequent
630	rate period. Cost reports must be reconciled within 5 years
631	after the end of the applicable fiscal year. Hospital rates
632	shall be subject to such limits or ceilings as may be
633	established in law or described in the agency's hospital
634	reimbursement plan. Specific exemptions to the limits or
635	ceilings may be provided in the General Appropriations Act. The
636	agency shall adjust a hospital's current inpatient per diem rate
637	to reflect the cost of serving the Medicaid population at that
638	institution if:
639	1.  The hospital experiences an increase in Medicaid
640	caseload by more than 25 percent in any year, primarily
641	resulting from the closure of a hospital in the same service
642	area occurring after July 1, 1995;
643	2.  The hospital's Medicaid per diem rate is at least 25
644	percent below the Medicaid per patient cost for that year; or
645	3.  The hospital is located in a county that has six or
646	fewer general acute care hospitals, began offering obstetrical
647	services on or after September 1999, and has submitted a request
648	in writing to the agency for a rate adjustment after July 1,
649	2000, but before September 30, 2000, in which case such
650	hospital's Medicaid inpatient per diem rate shall be adjusted to
651	cost, effective July 1, 2002.
652
653	By October 1 of each year, the agency must provide estimated
654	costs for any adjustment in a hospital inpatient per diem rate
655	to the Executive Office of the Governor, the House of
656	Representatives General Appropriations Committee, and the Senate
657	Appropriations Committee. Before the agency implements a change
658	in a hospital's inpatient per diem rate pursuant to this
659	paragraph, the Legislature must have specifically appropriated
660	sufficient funds in the General Appropriations Act to support
661	the increase in cost as estimated by the agency.
662	(g)  The agency shall develop a plan to convert inpatient
663	hospital rates to a prospective payment system that categorizes
664	each case into diagnosis-related groups (DRG) and assigns a
665	payment weight based on the average resources used to treat
666	Medicaid patients in that DRG. To the extent possible, the
667	agency shall propose an adaptation of an existing prospective
668	payment system, such as the one used by Medicare, and shall
669	propose such adjustments as are necessary for the Medicaid
670	population and to maintain budget neutrality for inpatient
671	hospital expenditures. The agency shall submit the Medicaid DRG
672	plan, identifying all steps necessary for the transition and any
673	costs associated with plan implementation, to the Governor, the
674	President of the Senate, and the Speaker of the House of
675	Representatives no later than January 1, 2013.
676	Section 9.  Subsection (10) of section 409.911, Florida
677	Statutes, is amended to read:
678	409.911  Disproportionate share program.-Subject to
679	specific allocations established within the General
680	Appropriations Act and any limitations established pursuant to
681	chapter 216, the agency shall distribute, pursuant to this
682	section, moneys to hospitals providing a disproportionate share
683	of Medicaid or charity care services by making quarterly
684	Medicaid payments as required. Notwithstanding the provisions of
685	s. 409.915, counties are exempt from contributing toward the
686	cost of this special reimbursement for hospitals serving a
687	disproportionate share of low-income patients.
688	(10)  The Agency for Health Care Administration shall
689	create a Medicaid Low-Income Pool Council by July 1, 2006. The
690	Low-Income Pool Council shall consist of 24 members, including 2
691	members appointed by the President of the Senate, 2 members
692	appointed by the Speaker of the House of Representatives, 3
693	representatives of statutory teaching hospitals, 3
694	representatives of public hospitals, 3 representatives of
695	nonprofit hospitals, 3 representatives of for-profit hospitals,
696	2 representatives of rural hospitals, 2 representatives of units
697	of local government which contribute funding, 1 representative
698	of family practice teaching hospitals, 1 representative of
699	federally qualified health centers, 1 representative from the
700	Department of Health, and 1 nonvoting representative of the
701	Agency for Health Care Administration who shall serve as chair
702	of the council. Except for a full-time employee of a public
703	entity, an individual who qualifies as a lobbyist under s.
704	11.045 or s. 112.3215 may not serve as a member of the council.
705	Of the members appointed by the Senate President, only one shall
706	be a physician. Of the members appointed by the Speaker of the
707	House of Representatives, only one shall be a physician. The
708	physician member appointed by the Senate President and the
709	physician member appointed by the Speaker of the House of
710	Representatives must be physicians who routinely take calls in a
711	trauma center, as defined in s. 395.4001, or a hospital
712	emergency department. The council shall:
713	(a)  Make recommendations on the financing of the low-
714	income pool and the disproportionate share hospital program and
715	the distribution of their funds.
716	(b)  Advise the Agency for Health Care Administration on
717	the development of the low-income pool plan required by the
718	federal Centers for Medicare and Medicaid Services pursuant to
719	the Medicaid reform waiver.
720	(c)  Advise the Agency for Health Care Administration on
721	the distribution of hospital funds used to adjust inpatient
722	hospital rates, rebase rates, or otherwise exempt hospitals from
723	reimbursement limits as financed by intergovernmental transfers.
724	(d)  Submit its findings and recommendations to the
725	Governor and the Legislature no later than February 1 of each
726	year.
727
728	This subsection expires October 1, 2014.
729	Section 10.  Subsection (4) of section 409.91195, Florida
730	Statutes, is amended to read:
731	409.91195  Medicaid Pharmaceutical and Therapeutics
732	Committee.-There is created a Medicaid Pharmaceutical and
733	Therapeutics Committee within the agency for the purpose of
734	developing a Medicaid preferred drug list.
735	(4)  Upon recommendation of the committee, the agency shall
736	adopt a preferred drug list as described in s. 409.912(37)(39).
737	To the extent feasible, the committee shall review all drug
738	classes included on the preferred drug list every 12 months, and
739	may recommend additions to and deletions from the preferred drug
740	list, such that the preferred drug list provides for medically
741	appropriate drug therapies for Medicaid patients which achieve
742	cost savings contained in the General Appropriations Act.
743	Section 11.  Subsection (1) of section 409.91196, Florida
744	Statutes, is amended to read:
745	409.91196  Supplemental rebate agreements; public records
746	and public meetings exemption.-
747	(1)  The rebate amount, percent of rebate, manufacturer's
748	pricing, and supplemental rebate, and other trade secrets as
749	defined in s. 688.002 that the agency has identified for use in
750	negotiations, held by the Agency for Health Care Administration
751	under s. 409.912(37)(39)(a)7. are confidential and exempt from
752	s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
753	Section 12.  Section 409.912, Florida Statutes, is amended
754	to read:
755	409.912  Cost-effective purchasing of health care.-The
756	agency shall purchase goods and services for Medicaid recipients
757	in the most cost-effective manner consistent with the delivery
758	of quality medical care. To ensure that medical services are
759	effectively utilized, the agency may, in any case, require a
760	confirmation or second physician's opinion of the correct
761	diagnosis for purposes of authorizing future services under the
762	Medicaid program. This section does not restrict access to
763	emergency services or poststabilization care services as defined
764	in 42 C.F.R. part 438.114. Such confirmation or second opinion
765	shall be rendered in a manner approved by the agency. The agency
766	shall maximize the use of prepaid per capita and prepaid
767	aggregate fixed-sum basis services when appropriate and other
768	alternative service delivery and reimbursement methodologies,
769	including competitive bidding pursuant to s. 287.057, designed
770	to facilitate the cost-effective purchase of a case-managed
771	continuum of care. The agency shall also require providers to
772	minimize the exposure of recipients to the need for acute
773	inpatient, custodial, and other institutional care and the
774	inappropriate or unnecessary use of high-cost services. The
775	agency shall contract with a vendor to monitor and evaluate the
776	clinical practice patterns of providers in order to identify
777	trends that are outside the normal practice patterns of a
778	provider's professional peers or the national guidelines of a
779	provider's professional association. The vendor must be able to
780	provide information and counseling to a provider whose practice
781	patterns are outside the norms, in consultation with the agency,
782	to improve patient care and reduce inappropriate utilization.
783	The agency may mandate prior authorization, drug therapy
784	management, or disease management participation for certain
785	populations of Medicaid beneficiaries, certain drug classes, or
786	particular drugs to prevent fraud, abuse, overuse, and possible
787	dangerous drug interactions. The Pharmaceutical and Therapeutics
788	Committee shall make recommendations to the agency on drugs for
789	which prior authorization is required. The agency shall inform
790	the Pharmaceutical and Therapeutics Committee of its decisions
791	regarding drugs subject to prior authorization. The agency is
792	authorized to limit the entities it contracts with or enrolls as
793	Medicaid providers by developing a provider network through
794	provider credentialing. The agency may competitively bid single-
795	source-provider contracts if procurement of goods or services
796	results in demonstrated cost savings to the state without
797	limiting access to care. The agency may limit its network based
798	on the assessment of beneficiary access to care, provider
799	availability, provider quality standards, time and distance
800	standards for access to care, the cultural competence of the
801	provider network, demographic characteristics of Medicaid
802	beneficiaries, practice and provider-to-beneficiary standards,
803	appointment wait times, beneficiary use of services, provider
804	turnover, provider profiling, provider licensure history,
805	previous program integrity investigations and findings, peer
806	review, provider Medicaid policy and billing compliance records,
807	clinical and medical record audits, and other factors. Providers
808	are shall not be entitled to enrollment in the Medicaid provider
809	network. The agency shall determine instances in which allowing
810	Medicaid beneficiaries to purchase durable medical equipment and
811	other goods is less expensive to the Medicaid program than long-
812	term rental of the equipment or goods. The agency may establish
813	rules to facilitate purchases in lieu of long-term rentals in
814	order to protect against fraud and abuse in the Medicaid program
815	as defined in s. 409.913. The agency may seek federal waivers
816	necessary to administer these policies.
817	(1)  The agency shall work with the Department of Children
818	and Family Services to ensure access of children and families in
819	the child protection system to needed and appropriate mental
820	health and substance abuse services. This subsection expires
821	October 1, 2014.
822	(2)  The agency may enter into agreements with appropriate
823	agents of other state agencies or of any agency of the Federal
824	Government and accept such duties in respect to social welfare
825	or public aid as may be necessary to implement the provisions of
826	Title XIX of the Social Security Act and ss. 409.901-409.920.
827	This subsection expires October 1, 2016.
828	(3)  The agency may contract with health maintenance
829	organizations certified pursuant to part I of chapter 641 for
830	the provision of services to recipients. This subsection expires
831	October 1, 2014.
832	(4)  The agency may contract with:
833	(a)  An entity that provides no prepaid health care
834	services other than Medicaid services under contract with the
835	agency and which is owned and operated by a county, county
836	health department, or county-owned and operated hospital to
837	provide health care services on a prepaid or fixed-sum basis to
838	recipients, which entity may provide such prepaid services
839	either directly or through arrangements with other providers.
840	Such prepaid health care services entities must be licensed
841	under parts I and III of chapter 641. An entity recognized under
842	this paragraph which demonstrates to the satisfaction of the
843	Office of Insurance Regulation of the Financial Services
844	Commission that it is backed by the full faith and credit of the
845	county in which it is located may be exempted from s. 641.225.
846	This paragraph expires October 1, 2014.
847	(b)  An entity that is providing comprehensive behavioral
848	health care services to certain Medicaid recipients through a
849	capitated, prepaid arrangement pursuant to the federal waiver
850	provided for by s. 409.905(5). Such entity must be licensed
851	under chapter 624, chapter 636, or chapter 641, or authorized
852	under paragraph (c) or paragraph (d), and must possess the
853	clinical systems and operational competence to manage risk and
854	provide comprehensive behavioral health care to Medicaid
855	recipients. As used in this paragraph, the term "comprehensive
856	behavioral health care services" means covered mental health and
857	substance abuse treatment services that are available to
858	Medicaid recipients. The secretary of the Department of Children
859	and Family Services shall approve provisions of procurements
860	related to children in the department's care or custody before
861	enrolling such children in a prepaid behavioral health plan. Any
862	contract awarded under this paragraph must be competitively
863	procured. In developing the behavioral health care prepaid plan
864	procurement document, the agency shall ensure that the
865	procurement document requires the contractor to develop and
866	implement a plan to ensure compliance with s. 394.4574 related
867	to services provided to residents of licensed assisted living
868	facilities that hold a limited mental health license. Except as
869	provided in subparagraph 5. 8., and except in counties where the
870	Medicaid managed care pilot program is authorized pursuant to s.
871	409.91211, the agency shall seek federal approval to contract
872	with a single entity meeting these requirements to provide
873	comprehensive behavioral health care services to all Medicaid
874	recipients not enrolled in a Medicaid managed care plan
875	authorized under s. 409.91211, a provider service network
876	authorized under paragraph (d), or a Medicaid health maintenance
877	organization in an AHCA area. In an AHCA area where the Medicaid
878	managed care pilot program is authorized pursuant to s.
879	409.91211 in one or more counties, the agency may procure a
880	contract with a single entity to serve the remaining counties as
881	an AHCA area or the remaining counties may be included with an
882	adjacent AHCA area and are subject to this paragraph. Each
883	entity must offer a sufficient choice of providers in its
884	network to ensure recipient access to care and the opportunity
885	to select a provider with whom they are satisfied. The network
886	shall include all public mental health hospitals. To ensure
887	unimpaired access to behavioral health care services by Medicaid
888	recipients, all contracts issued pursuant to this paragraph must
889	require 80 percent of the capitation paid to the managed care
890	plan, including health maintenance organizations and capitated
891	provider service networks, to be expended for the provision of
892	behavioral health care services. If the managed care plan
893	expends less than 80 percent of the capitation paid for the
894	provision of behavioral health care services, the difference
895	shall be returned to the agency. The agency shall provide the
896	plan with a certification letter indicating the amount of
897	capitation paid during each calendar year for behavioral health
898	care services pursuant to this section. The agency may reimburse
899	for substance abuse treatment services on a fee-for-service
900	basis until the agency finds that adequate funds are available
901	for capitated, prepaid arrangements.
902	1.  By January 1, 2001, The agency shall modify the
903	contracts with the entities providing comprehensive inpatient
904	and outpatient mental health care services to Medicaid
905	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
906	Counties, to include substance abuse treatment services.
907	2.  By July 1, 2003, the agency and the Department of
908	Children and Family Services shall execute a written agreement
909	that requires collaboration and joint development of all policy,
910	budgets, procurement documents, contracts, and monitoring plans
911	that have an impact on the state and Medicaid community mental
912	health and targeted case management programs.
913	2.3.  Except as provided in subparagraph 5. 8., by July 1,
914	2006, the agency and the Department of Children and Family
915	Services shall contract with managed care entities in each AHCA
916	area except area 6 or arrange to provide comprehensive inpatient
917	and outpatient mental health and substance abuse services
918	through capitated prepaid arrangements to all Medicaid
919	recipients who are eligible to participate in such plans under
920	federal law and regulation. In AHCA areas where eligible
921	individuals number less than 150,000, the agency shall contract
922	with a single managed care plan to provide comprehensive
923	behavioral health services to all recipients who are not
924	enrolled in a Medicaid health maintenance organization, a
925	provider service network authorized under paragraph (d), or a
926	Medicaid capitated managed care plan authorized under s.
927	409.91211. The agency may contract with more than one
928	comprehensive behavioral health provider to provide care to
929	recipients who are not enrolled in a Medicaid capitated managed
930	care plan authorized under s. 409.91211, a provider service
931	network authorized under paragraph (d), or a Medicaid health
932	maintenance organization in AHCA areas where the eligible
933	population exceeds 150,000. In an AHCA area where the Medicaid
934	managed care pilot program is authorized pursuant to s.
935	409.91211 in one or more counties, the agency may procure a
936	contract with a single entity to serve the remaining counties as
937	an AHCA area or the remaining counties may be included with an
938	adjacent AHCA area and shall be subject to this paragraph.
939	Contracts for comprehensive behavioral health providers awarded
940	pursuant to this section shall be competitively procured. Both
941	for-profit and not-for-profit corporations are eligible to
942	compete. Managed care plans contracting with the agency under
943	subsection (3) or paragraph (d), shall provide and receive
944	payment for the same comprehensive behavioral health benefits as
945	provided in AHCA rules, including handbooks incorporated by
946	reference. In AHCA area 11, the agency shall contract with at
947	least two comprehensive behavioral health care providers to
948	provide behavioral health care to recipients in that area who
949	are enrolled in, or assigned to, the MediPass program. One of
950	the behavioral health care contracts must be with the existing
951	provider service network pilot project, as described in
952	paragraph (d), for the purpose of demonstrating the cost-
953	effectiveness of the provision of quality mental health services
954	through a public hospital-operated managed care model. Payment
955	shall be at an agreed-upon capitated rate to ensure cost
956	savings. Of the recipients in area 11 who are assigned to
957	MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
958	MediPass-enrolled recipients shall be assigned to the existing
959	provider service network in area 11 for their behavioral care.
960	4.  By October 1, 2003, the agency and the department shall
961	submit a plan to the Governor, the President of the Senate, and
962	the Speaker of the House of Representatives which provides for
963	the full implementation of capitated prepaid behavioral health
964	care in all areas of the state.
965	a.  Implementation shall begin in 2003 in those AHCA areas
966	of the state where the agency is able to establish sufficient
967	capitation rates.
968	b.  If the agency determines that the proposed capitation
969	rate in any area is insufficient to provide appropriate
970	services, the agency may adjust the capitation rate to ensure
971	that care will be available. The agency and the department may
972	use existing general revenue to address any additional required
973	match but may not over-obligate existing funds on an annualized
974	basis.
975	c.  Subject to any limitations provided in the General
976	Appropriations Act, the agency, in compliance with appropriate
977	federal authorization, shall develop policies and procedures
978	that allow for certification of local and state funds.
979	3.5.  Children residing in a statewide inpatient
980	psychiatric program, or in a Department of Juvenile Justice or a
981	Department of Children and Family Services residential program
982	approved as a Medicaid behavioral health overlay services
983	provider may not be included in a behavioral health care prepaid
984	health plan or any other Medicaid managed care plan pursuant to
985	this paragraph.
986	6.  In converting to a prepaid system of delivery, the
987	agency shall in its procurement document require an entity
988	providing only comprehensive behavioral health care services to
989	prevent the displacement of indigent care patients by enrollees
990	in the Medicaid prepaid health plan providing behavioral health
991	care services from facilities receiving state funding to provide
992	indigent behavioral health care, to facilities licensed under
993	chapter 395 which do not receive state funding for indigent
994	behavioral health care, or reimburse the unsubsidized facility
995	for the cost of behavioral health care provided to the displaced
996	indigent care patient.
997	4.7.  Traditional community mental health providers under
998	contract with the Department of Children and Family Services
999	pursuant to part IV of chapter 394, child welfare providers
1000	under contract with the Department of Children and Family
1001	Services in areas 1 and 6, and inpatient mental health providers
1002	licensed pursuant to chapter 395 must be offered an opportunity
1003	to accept or decline a contract to participate in any provider
1004	network for prepaid behavioral health services.
1005	5.8.  All Medicaid-eligible children, except children in
1006	area 1 and children in Highlands County, Hardee County, Polk
1007	County, or Manatee County of area 6, that are open for child
1008	welfare services in the HomeSafeNet system, shall receive their
1009	behavioral health care services through a specialty prepaid plan
1010	operated by community-based lead agencies through a single
1011	agency or formal agreements among several agencies. The
1012	specialty prepaid plan must result in savings to the state
1013	comparable to savings achieved in other Medicaid managed care
1014	and prepaid programs. Such plan must provide mechanisms to
1015	maximize state and local revenues. The specialty prepaid plan
1016	shall be developed by the agency and the Department of Children
1017	and Family Services. The agency may seek federal waivers to
1018	implement this initiative. Medicaid-eligible children whose
1019	cases are open for child welfare services in the HomeSafeNet
1020	system and who reside in AHCA area 10 are exempt from the
1021	specialty prepaid plan upon the development of a service
1022	delivery mechanism for children who reside in area 10 as
1023	specified in s. 409.91211(3)(dd).
1024
1025	This paragraph expires October 1, 2014.
1026	(c)  A federally qualified health center or an entity owned
1027	by one or more federally qualified health centers or an entity
1028	owned by other migrant and community health centers receiving
1029	non-Medicaid financial support from the Federal Government to
1030	provide health care services on a prepaid or fixed-sum basis to
1031	recipients. A federally qualified health center or an entity
1032	that is owned by one or more federally qualified health centers
1033	and is reimbursed by the agency on a prepaid basis is exempt
1034	from parts I and III of chapter 641, but must comply with the
1035	solvency requirements in s. 641.2261(2) and meet the appropriate
1036	requirements governing financial reserve, quality assurance, and
1037	patients' rights established by the agency. This paragraph
1038	expires October 1, 2014.
1039	(d)1.  A provider service network may be reimbursed on a
1040	fee-for-service or prepaid basis. Prepaid provider service
1041	networks shall receive per-member, per-month payments. A
1042	provider service network that does not choose to be a prepaid
1043	plan shall receive fee-for-service rates with a shared savings
1044	settlement. The fee-for-service option shall be available to a
1045	provider service network only for the first 5 years of the
1046	plan's operation or until the contract year beginning October 1,
1047	2014, whichever is later. The agency shall annually conduct cost
1048	reconciliations to determine the amount of cost savings achieved
1049	by fee-for-service provider service networks for the dates of
1050	service in the period being reconciled. Only payments for
1051	covered services for dates of service within the reconciliation
1052	period and paid within 6 months after the last date of service
1053	in the reconciliation period shall be included. The agency shall
1054	perform the necessary adjustments for the inclusion of claims
1055	incurred but not reported within the reconciliation for claims
1056	that could be received and paid by the agency after the 6-month
1057	claims processing time lag. The agency shall provide the results
1058	of the reconciliations to the fee-for-service provider service
1059	networks within 45 days after the end of the reconciliation
1060	period. The fee-for-service provider service networks shall
1061	review and provide written comments or a letter of concurrence
1062	to the agency within 45 days after receipt of the reconciliation
1063	results. This reconciliation shall be considered final.
1064	2.  A provider service network which is reimbursed by the
1065	agency on a prepaid basis shall be exempt from parts I and III
1066	of chapter 641, but must comply with the solvency requirements
1067	in s. 641.2261(2) and meet appropriate financial reserve,
1068	quality assurance, and patient rights requirements as
1069	established by the agency.
1070	3.  Medicaid recipients assigned to a provider service
1071	network shall be chosen equally from those who would otherwise
1072	have been assigned to prepaid plans and MediPass. The agency is
1073	authorized to seek federal Medicaid waivers as necessary to
1074	implement the provisions of this section. This subparagraph
1075	expires October 1, 2014. Any contract previously awarded to a
1076	provider service network operated by a hospital pursuant to this
1077	subsection shall remain in effect for a period of 3 years
1078	following the current contract expiration date, regardless of
1079	any contractual provisions to the contrary.
1080	4.  A provider service network is a network established or
1081	organized and operated by a health care provider, or group of
1082	affiliated health care providers, including minority physician
1083	networks and emergency room diversion programs that meet the
1084	requirements of s. 409.91211, which provides a substantial
1085	proportion of the health care items and services under a
1086	contract directly through the provider or affiliated group of
1087	providers and may make arrangements with physicians or other
1088	health care professionals, health care institutions, or any
1089	combination of such individuals or institutions to assume all or
1090	part of the financial risk on a prospective basis for the
1091	provision of basic health services by the physicians, by other
1092	health professionals, or through the institutions. The health
1093	care providers must have a controlling interest in the governing
1094	body of the provider service network organization.
1095	(e)  An entity that provides only comprehensive behavioral
1096	health care services to certain Medicaid recipients through an
1097	administrative services organization agreement. Such an entity
1098	must possess the clinical systems and operational competence to
1099	provide comprehensive health care to Medicaid recipients. As
1100	used in this paragraph, the term "comprehensive behavioral
1101	health care services" means covered mental health and substance
1102	abuse treatment services that are available to Medicaid
1103	recipients. Any contract awarded under this paragraph must be
1104	competitively procured. The agency must ensure that Medicaid
1105	recipients have available the choice of at least two managed
1106	care plans for their behavioral health care services. This
1107	paragraph expires October 1, 2014.
1108	(f)  An entity that provides in-home physician services to
1109	test the cost-effectiveness of enhanced home-based medical care
1110	to Medicaid recipients with degenerative neurological diseases
1111	and other diseases or disabling conditions associated with high
1112	costs to Medicaid. The program shall be designed to serve very
1113	disabled persons and to reduce Medicaid reimbursed costs for
1114	inpatient, outpatient, and emergency department services. The
1115	agency shall contract with vendors on a risk-sharing basis.
1116	(g)  Children's provider networks that provide care
1117	coordination and care management for Medicaid-eligible pediatric
1118	patients, primary care, authorization of specialty care, and
1119	other urgent and emergency care through organized providers
1120	designed to service Medicaid eligibles under age 18 and
1121	pediatric emergency departments' diversion programs. The
1122	networks shall provide after-hour operations, including evening
1123	and weekend hours, to promote, when appropriate, the use of the
1124	children's networks rather than hospital emergency departments.
1125	(f)(h)  An entity authorized in s. 430.205 to contract with
1126	the agency and the Department of Elderly Affairs to provide
1127	health care and social services on a prepaid or fixed-sum basis
1128	to elderly recipients. Such prepaid health care services
1129	entities are exempt from the provisions of part I of chapter 641
1130	for the first 3 years of operation. An entity recognized under
1131	this paragraph that demonstrates to the satisfaction of the
1132	Office of Insurance Regulation that it is backed by the full
1133	faith and credit of one or more counties in which it operates
1134	may be exempted from s. 641.225. This paragraph expires October
1135	1, 2013.
1136	(g)(i)  A Children's Medical Services Network, as defined
1137	in s. 391.021. This paragraph expires October 1, 2014.
1138	(5)  The Agency for Health Care Administration, in
1139	partnership with the Department of Elderly Affairs, shall create
1140	an integrated, fixed-payment delivery program for Medicaid
1141	recipients who are 60 years of age or older or dually eligible
1142	for Medicare and Medicaid. The Agency for Health Care
1143	Administration shall implement the integrated program initially
1144	on a pilot basis in two areas of the state. The pilot areas
1145	shall be Area 7 and Area 11 of the Agency for Health Care
1146	Administration. Enrollment in the pilot areas shall be on a
1147	voluntary basis and in accordance with approved federal waivers
1148	and this section. The agency and its program contractors and
1149	providers shall not enroll any individual in the integrated
1150	program because the individual or the person legally responsible
1151	for the individual fails to choose to enroll in the integrated
1152	program. Enrollment in the integrated program shall be
1153	exclusively by affirmative choice of the eligible individual or
1154	by the person legally responsible for the individual. The
1155	integrated program must transfer all Medicaid services for
1156	eligible elderly individuals who choose to participate into an
1157	integrated-care management model designed to serve Medicaid
1158	recipients in the community. The integrated program must combine
1159	all funding for Medicaid services provided to individuals who
1160	are 60 years of age or older or dually eligible for Medicare and
1161	Medicaid into the integrated program, including funds for
1162	Medicaid home and community-based waiver services; all Medicaid
1163	services authorized in ss. 409.905 and 409.906, excluding funds
1164	for Medicaid nursing home services unless the agency is able to
1165	demonstrate how the integration of the funds will improve
1166	coordinated care for these services in a less costly manner; and
1167	Medicare coinsurance and deductibles for persons dually eligible
1168	for Medicaid and Medicare as prescribed in s. 409.908(13).
1169	(a)  Individuals who are 60 years of age or older or dually
1170	eligible for Medicare and Medicaid and enrolled in the
1171	developmental disabilities waiver program, the family and
1172	supported-living waiver program, the project AIDS care waiver
1173	program, the traumatic brain injury and spinal cord injury
1174	waiver program, the consumer-directed care waiver program, and
1175	the program of all-inclusive care for the elderly program, and
1176	residents of institutional care facilities for the
1177	developmentally disabled, must be excluded from the integrated
1178	program.
1179	(b)  Managed care entities who meet or exceed the agency's
1180	minimum standards are eligible to operate the integrated
1181	program. Entities eligible to participate include managed care
1182	organizations licensed under chapter 641, including entities
1183	eligible to participate in the nursing home diversion program,
1184	other qualified providers as defined in s. 430.703(7), community
1185	care for the elderly lead agencies, and other state-certified
1186	community service networks that meet comparable standards as
1187	defined by the agency, in consultation with the Department of
1188	Elderly Affairs and the Office of Insurance Regulation, to be
1189	financially solvent and able to take on financial risk for
1190	managed care. Community service networks that are certified
1191	pursuant to the comparable standards defined by the agency are
1192	not required to be licensed under chapter 641. Managed care
1193	entities who operate the integrated program shall be subject to
1194	s. 408.7056. Eligible entities shall choose to serve enrollees
1195	who are dually eligible for Medicare and Medicaid, enrollees who
1196	are 60 years of age or older, or both.
1197	(c)  The agency must ensure that the capitation-rate-
1198	setting methodology for the integrated program is actuarially
1199	sound and reflects the intent to provide quality care in the
1200	least restrictive setting. The agency must also require
1201	integrated-program providers to develop a credentialing system
1202	for service providers and to contract with all Gold Seal nursing
1203	homes, where feasible, and exclude, where feasible, chronically
1204	poor-performing facilities and providers as defined by the
1205	agency. The integrated program must develop and maintain an
1206	informal provider grievance system that addresses provider
1207	payment and contract problems. The agency shall also establish a
1208	formal grievance system to address those issues that were not
1209	resolved through the informal grievance system. The integrated
1210	program must provide that if the recipient resides in a
1211	noncontracted residential facility licensed under chapter 400 or
1212	chapter 429 at the time of enrollment in the integrated program,
1213	the recipient must be permitted to continue to reside in the
1214	noncontracted facility as long as the recipient desires. The
1215	integrated program must also provide that, in the absence of a
1216	contract between the integrated-program provider and the
1217	residential facility licensed under chapter 400 or chapter 429,
1218	current Medicaid rates must prevail. The integrated-program
1219	provider must ensure that electronic nursing home claims that
1220	contain sufficient information for processing are paid within 10
1221	business days after receipt. Alternately, the integrated-program
1222	provider may establish a capitated payment mechanism to
1223	prospectively pay nursing homes at the beginning of each month.
1224	The agency and the Department of Elderly Affairs must jointly
1225	develop procedures to manage the services provided through the
1226	integrated program in order to ensure quality and recipient
1227	choice.
1228	(d)  The Office of Program Policy Analysis and Government
1229	Accountability, in consultation with the Auditor General, shall
1230	comprehensively evaluate the pilot project for the integrated,
1231	fixed-payment delivery program for Medicaid recipients created
1232	under this subsection. The evaluation shall begin as soon as
1233	Medicaid recipients are enrolled in the managed care pilot
1234	program plans and shall continue for 24 months thereafter. The
1235	evaluation must include assessments of each managed care plan in
1236	the integrated program with regard to cost savings; consumer
1237	education, choice, and access to services; coordination of care;
1238	and quality of care. The evaluation must describe administrative
1239	or legal barriers to the implementation and operation of the
1240	pilot program and include recommendations regarding statewide
1241	expansion of the pilot program. The office shall submit its
1242	evaluation report to the Governor, the President of the Senate,
1243	and the Speaker of the House of Representatives no later than
1244	December 31, 2009.
1245	(e)  The agency may seek federal waivers or Medicaid state
1246	plan amendments and adopt rules as necessary to administer the
1247	integrated program. The agency may implement the approved
1248	federal waivers and other provisions as specified in this
1249	subsection.
1250	(f)  The implementation of the integrated, fixed-payment
1251	delivery program created under this subsection is subject to an
1252	appropriation in the General Appropriations Act.
1253	(5)(6)  The agency may contract with any public or private
1254	entity otherwise authorized by this section on a prepaid or
1255	fixed-sum basis for the provision of health care services to
1256	recipients. An entity may provide prepaid services to
1257	recipients, either directly or through arrangements with other
1258	entities, if each entity involved in providing services:
1259	(a)  Is organized primarily for the purpose of providing
1260	health care or other services of the type regularly offered to
1261	Medicaid recipients;
1262	(b)  Ensures that services meet the standards set by the
1263	agency for quality, appropriateness, and timeliness;
1264	(c)  Makes provisions satisfactory to the agency for
1265	insolvency protection and ensures that neither enrolled Medicaid
1266	recipients nor the agency will be liable for the debts of the
1267	entity;
1268	(d)  Submits to the agency, if a private entity, a
1269	financial plan that the agency finds to be fiscally sound and
1270	that provides for working capital in the form of cash or
1271	equivalent liquid assets excluding revenues from Medicaid
1272	premium payments equal to at least the first 3 months of
1273	operating expenses or $200,000, whichever is greater;
1274	(e)  Furnishes evidence satisfactory to the agency of
1275	adequate liability insurance coverage or an adequate plan of
1276	self-insurance to respond to claims for injuries arising out of
1277	the furnishing of health care;
1278	(f)  Provides, through contract or otherwise, for periodic
1279	review of its medical facilities and services, as required by
1280	the agency; and
1281	(g)  Provides organizational, operational, financial, and
1282	other information required by the agency.
1283
1284	This subsection expires October 1, 2014.
1285	(6)(7)  The agency may contract on a prepaid or fixed-sum
1286	basis with any health insurer that:
1287	(a)  Pays for health care services provided to enrolled
1288	Medicaid recipients in exchange for a premium payment paid by
1289	the agency;
1290	(b)  Assumes the underwriting risk; and
1291	(c)  Is organized and licensed under applicable provisions
1292	of the Florida Insurance Code and is currently in good standing
1293	with the Office of Insurance Regulation.
1294
1295	This subsection expires October 1, 2014.
1296	(7)(8)(a)  The agency may contract on a prepaid or fixed-
1297	sum basis with an exclusive provider organization to provide
1298	health care services to Medicaid recipients provided that the
1299	exclusive provider organization meets applicable managed care
1300	plan requirements in this section, ss. 409.9122, 409.9123,
1301	409.9128, and 627.6472, and other applicable provisions of law.
1302	This subsection expires October 1, 2014.
1303	(b)  For a period of no longer than 24 months after the
1304	effective date of this paragraph, when a member of an exclusive
1305	provider organization that is contracted by the agency to
1306	provide health care services to Medicaid recipients in rural
1307	areas without a health maintenance organization obtains services
1308	from a provider that participates in the Medicaid program in
1309	this state, the provider shall be paid in accordance with the
1310	appropriate fee schedule for services provided to eligible
1311	Medicaid recipients. The agency may seek waiver authority to
1312	implement this paragraph.
1313	(8)(9)  The Agency for Health Care Administration may
1314	provide cost-effective purchasing of chiropractic services on a
1315	fee-for-service basis to Medicaid recipients through
1316	arrangements with a statewide chiropractic preferred provider
1317	organization incorporated in this state as a not-for-profit
1318	corporation. The agency shall ensure that the benefit limits and
1319	prior authorization requirements in the current Medicaid program
1320	shall apply to the services provided by the chiropractic
1321	preferred provider organization. This subsection expires October
1322	1, 2014.
1323	(9)(10)  The agency shall not contract on a prepaid or
1324	fixed-sum basis for Medicaid services with an entity which knows
1325	or reasonably should know that any officer, director, agent,
1326	managing employee, or owner of stock or beneficial interest in
1327	excess of 5 percent common or preferred stock, or the entity
1328	itself, has been found guilty of, regardless of adjudication, or
1329	entered a plea of nolo contendere, or guilty, to:
1330	(a)  Fraud;
1331	(b)  Violation of federal or state antitrust statutes,
1332	including those proscribing price fixing between competitors and
1333	the allocation of customers among competitors;
1334	(c)  Commission of a felony involving embezzlement, theft,
1335	forgery, income tax evasion, bribery, falsification or
1336	destruction of records, making false statements, receiving
1337	stolen property, making false claims, or obstruction of justice;
1338	or
1339	(d)  Any crime in any jurisdiction which directly relates
1340	to the provision of health services on a prepaid or fixed-sum
1341	basis.
1342
1343	This subsection expires October 1, 2014.
1344	(10)(11)  The agency, after notifying the Legislature, may
1345	apply for waivers of applicable federal laws and regulations as
1346	necessary to implement more appropriate systems of health care
1347	for Medicaid recipients and reduce the cost of the Medicaid
1348	program to the state and federal governments and shall implement
1349	such programs, after legislative approval, within a reasonable
1350	period of time after federal approval. These programs must be
1351	designed primarily to reduce the need for inpatient care,
1352	custodial care and other long-term or institutional care, and
1353	other high-cost services. Prior to seeking legislative approval
1354	of such a waiver as authorized by this subsection, the agency
1355	shall provide notice and an opportunity for public comment.
1356	Notice shall be provided to all persons who have made requests
1357	of the agency for advance notice and shall be published in the
1358	Florida Administrative Weekly not less than 28 days prior to the
1359	intended action. This subsection expires October 1, 2016.
1360	(11)(12)  The agency shall establish a postpayment
1361	utilization control program designed to identify recipients who
1362	may inappropriately overuse or underuse Medicaid services and
1363	shall provide methods to correct such misuse. This subsection
1364	expires October 1, 2014.
1365	(12)(13)  The agency shall develop and provide coordinated
1366	systems of care for Medicaid recipients and may contract with
1367	public or private entities to develop and administer such
1368	systems of care among public and private health care providers
1369	in a given geographic area. This subsection expires October 1,
1370	2014.
1371	(13)(14)(a)  The agency shall operate or contract for the
1372	operation of utilization management and incentive systems
1373	designed to encourage cost-effective use of services and to
1374	eliminate services that are medically unnecessary. The agency
1375	shall track Medicaid provider prescription and billing patterns
1376	and evaluate them against Medicaid medical necessity criteria
1377	and coverage and limitation guidelines adopted by rule. Medical
1378	necessity determination requires that service be consistent with
1379	symptoms or confirmed diagnosis of illness or injury under
1380	treatment and not in excess of the patient's needs. The agency
1381	shall conduct reviews of provider exceptions to peer group norms
1382	and shall, using statistical methodologies, provider profiling,
1383	and analysis of billing patterns, detect and investigate
1384	abnormal or unusual increases in billing or payment of claims
1385	for Medicaid services and medically unnecessary provision of
1386	services. Providers that demonstrate a pattern of submitting
1387	claims for medically unnecessary services shall be referred to
1388	the Medicaid program integrity unit for investigation. In its
1389	annual report, required in s. 409.913, the agency shall report
1390	on its efforts to control overutilization as described in this
1391	subsection paragraph. This subsection expires October 1, 2014.
1392	(b)  The agency shall develop a procedure for determining
1393	whether health care providers and service vendors can provide
1394	the Medicaid program using a business case that demonstrates
1395	whether a particular good or service can offset the cost of
1396	providing the good or service in an alternative setting or
1397	through other means and therefore should receive a higher
1398	reimbursement. The business case must include, but need not be
1399	limited to:
1400	1.  A detailed description of the good or service to be
1401	provided, a description and analysis of the agency's current
1402	performance of the service, and a rationale documenting how
1403	providing the service in an alternative setting would be in the
1404	best interest of the state, the agency, and its clients.
1405	2.  A cost-benefit analysis documenting the estimated
1406	specific direct and indirect costs, savings, performance
1407	improvements, risks, and qualitative and quantitative benefits
1408	involved in or resulting from providing the service. The cost-
1409	benefit analysis must include a detailed plan and timeline
1410	identifying all actions that must be implemented to realize
1411	expected benefits. The Secretary of Health Care Administration
1412	shall verify that all costs, savings, and benefits are valid and
1413	achievable.
1414	(c)  If the agency determines that the increased
1415	reimbursement is cost-effective, the agency shall recommend a
1416	change in the reimbursement schedule for that particular good or
1417	service. If, within 12 months after implementing any rate change
1418	under this procedure, the agency determines that costs were not
1419	offset by the increased reimbursement schedule, the agency may
1420	revert to the former reimbursement schedule for the particular
1421	good or service.
1422	(14)(15)(a)  The agency shall operate the Comprehensive
1423	Assessment and Review for Long-Term Care Services (CARES)
1424	nursing facility preadmission screening program to ensure that
1425	Medicaid payment for nursing facility care is made only for
1426	individuals whose conditions require such care and to ensure
1427	that long-term care services are provided in the setting most
1428	appropriate to the needs of the person and in the most
1429	economical manner possible. The CARES program shall also ensure
1430	that individuals participating in Medicaid home and community-
1431	based waiver programs meet criteria for those programs,
1432	consistent with approved federal waivers.
1433	(b)  The agency shall operate the CARES program through an
1434	interagency agreement with the Department of Elderly Affairs.
1435	The agency, in consultation with the Department of Elderly
1436	Affairs, may contract for any function or activity of the CARES
1437	program, including any function or activity required by 42
1438	C.F.R. part 483.20, relating to preadmission screening and
1439	resident review.
1440	(c)  Prior to making payment for nursing facility services
1441	for a Medicaid recipient, the agency must verify that the
1442	nursing facility preadmission screening program has determined
1443	that the individual requires nursing facility care and that the
1444	individual cannot be safely served in community-based programs.
1445	The nursing facility preadmission screening program shall refer
1446	a Medicaid recipient to a community-based program if the
1447	individual could be safely served at a lower cost and the
1448	recipient chooses to participate in such program. For
1449	individuals whose nursing home stay is initially funded by
1450	Medicare and Medicare coverage is being terminated for lack of
1451	progress towards rehabilitation, CARES staff shall consult with
1452	the person making the determination of progress toward
1453	rehabilitation to ensure that the recipient is not being
1454	inappropriately disqualified from Medicare coverage. If, in
1455	their professional judgment, CARES staff believes that a
1456	Medicare beneficiary is still making progress toward
1457	rehabilitation, they may assist the Medicare beneficiary with an
1458	appeal of the disqualification from Medicare coverage. The use
1459	of CARES teams to review Medicare denials for coverage under
1460	this section is authorized only if it is determined that such
1461	reviews qualify for federal matching funds through Medicaid. The
1462	agency shall seek or amend federal waivers as necessary to
1463	implement this section.
1464	(d)  For the purpose of initiating immediate prescreening
1465	and diversion assistance for individuals residing in nursing
1466	homes and in order to make families aware of alternative long-
1467	term care resources so that they may choose a more cost-
1468	effective setting for long-term placement, CARES staff shall
1469	conduct an assessment and review of a sample of individuals
1470	whose nursing home stay is expected to exceed 20 days,
1471	regardless of the initial funding source for the nursing home
1472	placement. CARES staff shall provide counseling and referral
1473	services to these individuals regarding choosing appropriate
1474	long-term care alternatives. This paragraph does not apply to
1475	continuing care facilities licensed under chapter 651 or to
1476	retirement communities that provide a combination of nursing
1477	home, independent living, and other long-term care services.
1478	(e)  By January 15 of each year, the agency shall submit a
1479	report to the Legislature describing the operations of the CARES
1480	program. The report must describe:
1481	1.  Rate of diversion to community alternative programs;
1482	2.  CARES program staffing needs to achieve additional
1483	diversions;
1484	3.  Reasons the program is unable to place individuals in
1485	less restrictive settings when such individuals desired such
1486	services and could have been served in such settings;
1487	4.  Barriers to appropriate placement, including barriers
1488	due to policies or operations of other agencies or state-funded
1489	programs; and
1490	5.  Statutory changes necessary to ensure that individuals
1491	in need of long-term care services receive care in the least
1492	restrictive environment.
1493	(f)  The Department of Elderly Affairs shall track
1494	individuals over time who are assessed under the CARES program
1495	and who are diverted from nursing home placement. By January 15
1496	of each year, the department shall submit to the Legislature a
1497	longitudinal study of the individuals who are diverted from
1498	nursing home placement. The study must include:
1499	1.  The demographic characteristics of the individuals
1500	assessed and diverted from nursing home placement, including,
1501	but not limited to, age, race, gender, frailty, caregiver
1502	status, living arrangements, and geographic location;
1503	2.  A summary of community services provided to individuals
1504	for 1 year after assessment and diversion;
1505	3.  A summary of inpatient hospital admissions for
1506	individuals who have been diverted; and
1507	4.  A summary of the length of time between diversion and
1508	subsequent entry into a nursing home or death.
1509
1510	This subsection expires October 1, 2013.
1511	(15)(16)(a)  The agency shall identify health care
1512	utilization and price patterns within the Medicaid program which
1513	are not cost-effective or medically appropriate and assess the
1514	effectiveness of new or alternate methods of providing and
1515	monitoring service, and may implement such methods as it
1516	considers appropriate. Such methods may include disease
1517	management initiatives, an integrated and systematic approach
1518	for managing the health care needs of recipients who are at risk
1519	of or diagnosed with a specific disease by using best practices,
1520	prevention strategies, clinical-practice improvement, clinical
1521	interventions and protocols, outcomes research, information
1522	technology, and other tools and resources to reduce overall
1523	costs and improve measurable outcomes.
1524	(b)  The responsibility of the agency under this subsection
1525	shall include the development of capabilities to identify actual
1526	and optimal practice patterns; patient and provider educational
1527	initiatives; methods for determining patient compliance with
1528	prescribed treatments; fraud, waste, and abuse prevention and
1529	detection programs; and beneficiary case management programs.
1530	1.  The practice pattern identification program shall
1531	evaluate practitioner prescribing patterns based on national and
1532	regional practice guidelines, comparing practitioners to their
1533	peer groups. The agency and its Drug Utilization Review Board
1534	shall consult with the Department of Health and a panel of
1535	practicing health care professionals consisting of the
1536	following: the Speaker of the House of Representatives and the
1537	President of the Senate shall each appoint three physicians
1538	licensed under chapter 458 or chapter 459; and the Governor
1539	shall appoint two pharmacists licensed under chapter 465 and one
1540	dentist licensed under chapter 466 who is an oral surgeon. Terms
1541	of the panel members shall expire at the discretion of the
1542	appointing official. The advisory panel shall be responsible for
1543	evaluating treatment guidelines and recommending ways to
1544	incorporate their use in the practice pattern identification
1545	program. Practitioners who are prescribing inappropriately or
1546	inefficiently, as determined by the agency, may have their
1547	prescribing of certain drugs subject to prior authorization or
1548	may be terminated from all participation in the Medicaid
1549	program.
1550	2.  The agency shall also develop educational interventions
1551	designed to promote the proper use of medications by providers
1552	and beneficiaries.
1553	3.  The agency shall implement a pharmacy fraud, waste, and
1554	abuse initiative that may include a surety bond or letter of
1555	credit requirement for participating pharmacies, enhanced
1556	provider auditing practices, the use of additional fraud and
1557	abuse software, recipient management programs for beneficiaries
1558	inappropriately using their benefits, and other steps that will
1559	eliminate provider and recipient fraud, waste, and abuse. The
1560	initiative shall address enforcement efforts to reduce the
1561	number and use of counterfeit prescriptions.
1562	4.  By September 30, 2002, the agency shall contract with
1563	an entity in the state to implement a wireless handheld clinical
1564	pharmacology drug information database for practitioners. The
1565	initiative shall be designed to enhance the agency's efforts to
1566	reduce fraud, abuse, and errors in the prescription drug benefit
1567	program and to otherwise further the intent of this paragraph.
1568	5.  By April 1, 2006, the agency shall contract with an
1569	entity to design a database of clinical utilization information
1570	or electronic medical records for Medicaid providers. This
1571	system must be web-based and allow providers to review on a
1572	real-time basis the utilization of Medicaid services, including,
1573	but not limited to, physician office visits, inpatient and
1574	outpatient hospitalizations, laboratory and pathology services,
1575	radiological and other imaging services, dental care, and
1576	patterns of dispensing prescription drugs in order to coordinate
1577	care and identify potential fraud and abuse.
1578	6.  The agency may apply for any federal waivers needed to
1579	administer this paragraph.
1580
1581	This subsection expires October 1, 2014.
1582	(16)(17)  An entity contracting on a prepaid or fixed-sum
1583	basis shall meet the surplus requirements of s. 641.225. If an
1584	entity's surplus falls below an amount equal to the surplus
1585	requirements of s. 641.225, the agency shall prohibit the entity
1586	from engaging in marketing and preenrollment activities, shall
1587	cease to process new enrollments, and may not renew the entity's
1588	contract until the required balance is achieved. The
1589	requirements of this subsection do not apply:
1590	(a)  Where a public entity agrees to fund any deficit
1591	incurred by the contracting entity; or
1592	(b)  Where the entity's performance and obligations are
1593	guaranteed in writing by a guaranteeing organization which:
1594	1.  Has been in operation for at least 5 years and has
1595	assets in excess of $50 million; or
1596	2.  Submits a written guarantee acceptable to the agency
1597	which is irrevocable during the term of the contracting entity's
1598	contract with the agency and, upon termination of the contract,
1599	until the agency receives proof of satisfaction of all
1600	outstanding obligations incurred under the contract.
1601
1602	This subsection expires October 1, 2014.
1603	(17)(18)(a)  The agency may require an entity contracting
1604	on a prepaid or fixed-sum basis to establish a restricted
1605	insolvency protection account with a federally guaranteed
1606	financial institution licensed to do business in this state. The
1607	entity shall deposit into that account 5 percent of the
1608	capitation payments made by the agency each month until a
1609	maximum total of 2 percent of the total current contract amount
1610	is reached. The restricted insolvency protection account may be
1611	drawn upon with the authorized signatures of two persons
1612	designated by the entity and two representatives of the agency.
1613	If the agency finds that the entity is insolvent, the agency may
1614	draw upon the account solely with the two authorized signatures
1615	of representatives of the agency, and the funds may be disbursed
1616	to meet financial obligations incurred by the entity under the
1617	prepaid contract. If the contract is terminated, expired, or not
1618	continued, the account balance must be released by the agency to
1619	the entity upon receipt of proof of satisfaction of all
1620	outstanding obligations incurred under this contract.
1621	(b)  The agency may waive the insolvency protection account
1622	requirement in writing when evidence is on file with the agency
1623	of adequate insolvency insurance and reinsurance that will
1624	protect enrollees if the entity becomes unable to meet its
1625	obligations.
1626
1627	This subsection expires October 1, 2014.
1628	(18)(19)  An entity that contracts with the agency on a
1629	prepaid or fixed-sum basis for the provision of Medicaid
1630	services shall reimburse any hospital or physician that is
1631	outside the entity's authorized geographic service area as
1632	specified in its contract with the agency, and that provides
1633	services authorized by the entity to its members, at a rate
1634	negotiated with the hospital or physician for the provision of
1635	services or according to the lesser of the following:
1636	(a)  The usual and customary charges made to the general
1637	public by the hospital or physician; or
1638	(b)  The Florida Medicaid reimbursement rate established
1639	for the hospital or physician.
1640
1641	This subsection expires October 1, 2014.
1642	(19)(20)  When a merger or acquisition of a Medicaid
1643	prepaid contractor has been approved by the Office of Insurance
1644	Regulation pursuant to s. 628.4615, the agency shall approve the
1645	assignment or transfer of the appropriate Medicaid prepaid
1646	contract upon request of the surviving entity of the merger or
1647	acquisition if the contractor and the other entity have been in
1648	good standing with the agency for the most recent 12-month
1649	period, unless the agency determines that the assignment or
1650	transfer would be detrimental to the Medicaid recipients or the
1651	Medicaid program. To be in good standing, an entity must not
1652	have failed accreditation or committed any material violation of
1653	the requirements of s. 641.52 and must meet the Medicaid
1654	contract requirements. For purposes of this section, a merger or
1655	acquisition means a change in controlling interest of an entity,
1656	including an asset or stock purchase. This subsection expires
1657	October 1, 2014.
1658	(20)(21)  Any entity contracting with the agency pursuant
1659	to this section to provide health care services to Medicaid
1660	recipients is prohibited from engaging in any of the following
1661	practices or activities:
1662	(a)  Practices that are discriminatory, including, but not
1663	limited to, attempts to discourage participation on the basis of
1664	actual or perceived health status.
1665	(b)  Activities that could mislead or confuse recipients,
1666	or misrepresent the organization, its marketing representatives,
1667	or the agency. Violations of this paragraph include, but are not
1668	limited to:
1669	1.  False or misleading claims that marketing
1670	representatives are employees or representatives of the state or
1671	county, or of anyone other than the entity or the organization
1672	by whom they are reimbursed.
1673	2.  False or misleading claims that the entity is
1674	recommended or endorsed by any state or county agency, or by any
1675	other organization which has not certified its endorsement in
1676	writing to the entity.
1677	3.  False or misleading claims that the state or county
1678	recommends that a Medicaid recipient enroll with an entity.
1679	4.  Claims that a Medicaid recipient will lose benefits
1680	under the Medicaid program, or any other health or welfare
1681	benefits to which the recipient is legally entitled, if the
1682	recipient does not enroll with the entity.
1683	(c)  Granting or offering of any monetary or other valuable
1684	consideration for enrollment, except as authorized by subsection
1685	(23) (24).
1686	(d)  Door-to-door solicitation of recipients who have not
1687	contacted the entity or who have not invited the entity to make
1688	a presentation.
1689	(e)  Solicitation of Medicaid recipients by marketing
1690	representatives stationed in state offices unless approved and
1691	supervised by the agency or its agent and approved by the
1692	affected state agency when solicitation occurs in an office of
1693	the state agency. The agency shall ensure that marketing
1694	representatives stationed in state offices shall market their
1695	managed care plans to Medicaid recipients only in designated
1696	areas and in such a way as to not interfere with the recipients'
1697	activities in the state office.
1698	(f)  Enrollment of Medicaid recipients.
1699
1700	This subsection expires October 1, 2014.
1701	(21)(22)  The agency may impose a fine for a violation of
1702	this section or the contract with the agency by a person or
1703	entity that is under contract with the agency. With respect to
1704	any nonwillful violation, such fine shall not exceed $2,500 per
1705	violation. In no event shall such fine exceed an aggregate
1706	amount of $10,000 for all nonwillful violations arising out of
1707	the same action. With respect to any knowing and willful
1708	violation of this section or the contract with the agency, the
1709	agency may impose a fine upon the entity in an amount not to
1710	exceed $20,000 for each such violation. In no event shall such
1711	fine exceed an aggregate amount of $100,000 for all knowing and
1712	willful violations arising out of the same action. This
1713	subsection expires October 1, 2014.
1714	(22)(23)  A health maintenance organization or a person or
1715	entity exempt from chapter 641 that is under contract with the
1716	agency for the provision of health care services to Medicaid
1717	recipients may not use or distribute marketing materials used to
1718	solicit Medicaid recipients, unless such materials have been
1719	approved by the agency. The provisions of this subsection do not
1720	apply to general advertising and marketing materials used by a
1721	health maintenance organization to solicit both non-Medicaid
1722	subscribers and Medicaid recipients. This subsection expires
1723	October 1, 2014.
1724	(23)(24)  Upon approval by the agency, health maintenance
1725	organizations and persons or entities exempt from chapter 641
1726	that are under contract with the agency for the provision of
1727	health care services to Medicaid recipients may be permitted
1728	within the capitation rate to provide additional health benefits
1729	that the agency has found are of high quality, are practicably
1730	available, provide reasonable value to the recipient, and are
1731	provided at no additional cost to the state. This subsection
1732	expires October 1, 2014.
1733	(24)(25)  The agency shall utilize the statewide health
1734	maintenance organization complaint hotline for the purpose of
1735	investigating and resolving Medicaid and prepaid health plan
1736	complaints, maintaining a record of complaints and confirmed
1737	problems, and receiving disenrollment requests made by
1738	recipients. This subsection expires October 1, 2014.
1739	(25)(26)  The agency shall require the publication of the
1740	health maintenance organization's and the prepaid health plan's
1741	consumer services telephone numbers and the "800" telephone
1742	number of the statewide health maintenance organization
1743	complaint hotline on each Medicaid identification card issued by
1744	a health maintenance organization or prepaid health plan
1745	contracting with the agency to serve Medicaid recipients and on
1746	each subscriber handbook issued to a Medicaid recipient. This
1747	subsection expires October 1, 2014.
1748	(26)(27)  The agency shall establish a health care quality
1749	improvement system for those entities contracting with the
1750	agency pursuant to this section, incorporating all the standards
1751	and guidelines developed by the Medicaid Bureau of the Health
1752	Care Financing Administration as a part of the quality assurance
1753	reform initiative. The system shall include, but need not be
1754	limited to, the following:
1755	(a)  Guidelines for internal quality assurance programs,
1756	including standards for:
1757	1.  Written quality assurance program descriptions.
1758	2.  Responsibilities of the governing body for monitoring,
1759	evaluating, and making improvements to care.
1760	3.  An active quality assurance committee.
1761	4.  Quality assurance program supervision.
1762	5.  Requiring the program to have adequate resources to
1763	effectively carry out its specified activities.
1764	6.  Provider participation in the quality assurance
1765	program.
1766	7.  Delegation of quality assurance program activities.
1767	8.  Credentialing and recredentialing.
1768	9.  Enrollee rights and responsibilities.
1769	10.  Availability and accessibility to services and care.
1770	11.  Ambulatory care facilities.
1771	12.  Accessibility and availability of medical records, as
1772	well as proper recordkeeping and process for record review.
1773	13.  Utilization review.
1774	14.  A continuity of care system.
1775	15.  Quality assurance program documentation.
1776	16.  Coordination of quality assurance activity with other
1777	management activity.
1778	17.  Delivering care to pregnant women and infants; to
1779	elderly and disabled recipients, especially those who are at
1780	risk of institutional placement; to persons with developmental
1781	disabilities; and to adults who have chronic, high-cost medical
1782	conditions.
1783	(b)  Guidelines which require the entities to conduct
1784	quality-of-care studies which:
1785	1.  Target specific conditions and specific health service
1786	delivery issues for focused monitoring and evaluation.
1787	2.  Use clinical care standards or practice guidelines to
1788	objectively evaluate the care the entity delivers or fails to
1789	deliver for the targeted clinical conditions and health services
1790	delivery issues.
1791	3.  Use quality indicators derived from the clinical care
1792	standards or practice guidelines to screen and monitor care and
1793	services delivered.
1794	(c)  Guidelines for external quality review of each
1795	contractor which require: focused studies of patterns of care;
1796	individual care review in specific situations; and followup
1797	activities on previous pattern-of-care study findings and
1798	individual-care-review findings. In designing the external
1799	quality review function and determining how it is to operate as
1800	part of the state's overall quality improvement system, the
1801	agency shall construct its external quality review organization
1802	and entity contracts to address each of the following:
1803	1.  Delineating the role of the external quality review
1804	organization.
1805	2.  Length of the external quality review organization
1806	contract with the state.
1807	3.  Participation of the contracting entities in designing
1808	external quality review organization review activities.
1809	4.  Potential variation in the type of clinical conditions
1810	and health services delivery issues to be studied at each plan.
1811	5.  Determining the number of focused pattern-of-care
1812	studies to be conducted for each plan.
1813	6.  Methods for implementing focused studies.
1814	7.  Individual care review.
1815	8.  Followup activities.
1816
1817	This subsection expires October 1, 2016.
1818	(27)(28)  In order to ensure that children receive health
1819	care services for which an entity has already been compensated,
1820	an entity contracting with the agency pursuant to this section
1821	shall achieve an annual Early and Periodic Screening, Diagnosis,
1822	and Treatment (EPSDT) Service screening rate of at least 60
1823	percent for those recipients continuously enrolled for at least
1824	8 months. The agency shall develop a method by which the EPSDT
1825	screening rate shall be calculated. For any entity which does
1826	not achieve the annual 60 percent rate, the entity must submit a
1827	corrective action plan for the agency's approval. If the entity
1828	does not meet the standard established in the corrective action
1829	plan during the specified timeframe, the agency is authorized to
1830	impose appropriate contract sanctions. At least annually, the
1831	agency shall publicly release the EPSDT Services screening rates
1832	of each entity it has contracted with on a prepaid basis to
1833	serve Medicaid recipients. This subsection expires October 1,
1834	2014.
1835	(28)(29)  The agency shall perform enrollments and
1836	disenrollments for Medicaid recipients who are eligible for
1837	MediPass or managed care plans. Notwithstanding the prohibition
1838	contained in paragraph (20)(21)(f), managed care plans may
1839	perform preenrollments of Medicaid recipients under the
1840	supervision of the agency or its agents. For the purposes of
1841	this section, the term "preenrollment" means the provision of
1842	marketing and educational materials to a Medicaid recipient and
1843	assistance in completing the application forms, but does not
1844	include actual enrollment into a managed care plan. An
1845	application for enrollment may not be deemed complete until the
1846	agency or its agent verifies that the recipient made an
1847	informed, voluntary choice. The agency, in cooperation with the
1848	Department of Children and Family Services, may test new
1849	marketing initiatives to inform Medicaid recipients about their
1850	managed care options at selected sites. The agency may contract
1851	with a third party to perform managed care plan and MediPass
1852	enrollment and disenrollment services for Medicaid recipients
1853	and may adopt rules to administer such services. The agency may
1854	adjust the capitation rate only to cover the costs of a third-
1855	party enrollment and disenrollment contract, and for agency
1856	supervision and management of the managed care plan enrollment
1857	and disenrollment contract. This subsection expires October 1,
1858	2014.
1859	(29)(30)  Any lists of providers made available to Medicaid
1860	recipients, MediPass enrollees, or managed care plan enrollees
1861	shall be arranged alphabetically showing the provider's name and
1862	specialty and, separately, by specialty in alphabetical order.
1863	This subsection expires October 1, 2014.
1864	(30)(31)  The agency shall establish an enhanced managed
1865	care quality assurance oversight function, to include at least
1866	the following components:
1867	(a)  At least quarterly analysis and followup, including
1868	sanctions as appropriate, of managed care participant
1869	utilization of services.
1870	(b)  At least quarterly analysis and followup, including
1871	sanctions as appropriate, of quality findings of the Medicaid
1872	peer review organization and other external quality assurance
1873	programs.
1874	(c)  At least quarterly analysis and followup, including
1875	sanctions as appropriate, of the fiscal viability of managed
1876	care plans.
1877	(d)  At least quarterly analysis and followup, including
1878	sanctions as appropriate, of managed care participant
1879	satisfaction and disenrollment surveys.
1880	(e)  The agency shall conduct regular and ongoing Medicaid
1881	recipient satisfaction surveys.
1882
1883	The analyses and followup activities conducted by the agency
1884	under its enhanced managed care quality assurance oversight
1885	function shall not duplicate the activities of accreditation
1886	reviewers for entities regulated under part III of chapter 641,
1887	but may include a review of the finding of such reviewers. This
1888	subsection expires October 1, 2014.
1889	(31)(32)  Each managed care plan that is under contract
1890	with the agency to provide health care services to Medicaid
1891	recipients shall annually conduct a background check with the
1892	Department of Law Enforcement of all persons with ownership
1893	interest of 5 percent or more or executive management
1894	responsibility for the managed care plan and shall submit to the
1895	agency information concerning any such person who has been found
1896	guilty of, regardless of adjudication, or has entered a plea of
1897	nolo contendere or guilty to, any of the offenses listed in s.
1898	435.04. This subsection expires October 1, 2014.
1899	(32)(33)  The agency shall, by rule, develop a process
1900	whereby a Medicaid managed care plan enrollee who wishes to
1901	enter hospice care may be disenrolled from the managed care plan
1902	within 24 hours after contacting the agency regarding such
1903	request. The agency rule shall include a methodology for the
1904	agency to recoup managed care plan payments on a pro rata basis
1905	if payment has been made for the enrollment month when
1906	disenrollment occurs. This subsection expires October 1, 2014.
1907	(33)(34)  The agency and entities that contract with the
1908	agency to provide health care services to Medicaid recipients
1909	under this section or ss. 409.91211 and 409.9122 must comply
1910	with the provisions of s. 641.513 in providing emergency
1911	services and care to Medicaid recipients and MediPass
1912	recipients. Where feasible, safe, and cost-effective, the agency
1913	shall encourage hospitals, emergency medical services providers,
1914	and other public and private health care providers to work
1915	together in their local communities to enter into agreements or
1916	arrangements to ensure access to alternatives to emergency
1917	services and care for those Medicaid recipients who need
1918	nonemergent care. The agency shall coordinate with hospitals,
1919	emergency medical services providers, private health plans,
1920	capitated managed care networks as established in s. 409.91211,
1921	and other public and private health care providers to implement
1922	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1923	and 641.31097 to develop and implement emergency department
1924	diversion programs for Medicaid recipients. This subsection
1925	expires October 1, 2014.
1926	(34)(35)  All entities providing health care services to
1927	Medicaid recipients shall make available, and encourage all
1928	pregnant women and mothers with infants to receive, and provide
1929	documentation in the medical records to reflect, the following:
1930	(a)  Healthy Start prenatal or infant screening.
1931	(b)  Healthy Start care coordination, when screening or
1932	other factors indicate need.
1933	(c)  Healthy Start enhanced services in accordance with the
1934	prenatal or infant screening results.
1935	(d)  Immunizations in accordance with recommendations of
1936	the Advisory Committee on Immunization Practices of the United
1937	States Public Health Service and the American Academy of
1938	Pediatrics, as appropriate.
1939	(e)  Counseling and services for family planning to all
1940	women and their partners.
1941	(f)  A scheduled postpartum visit for the purpose of
1942	voluntary family planning, to include discussion of all methods
1943	of contraception, as appropriate.
1944	(g)  Referral to the Special Supplemental Nutrition Program
1945	for Women, Infants, and Children (WIC).
1946
1947	This subsection expires October 1, 2014.
1948	(35)(36)  Any entity that provides Medicaid prepaid health
1949	plan services shall ensure the appropriate coordination of
1950	health care services with an assisted living facility in cases
1951	where a Medicaid recipient is both a member of the entity's
1952	prepaid health plan and a resident of the assisted living
1953	facility. If the entity is at risk for Medicaid targeted case
1954	management and behavioral health services, the entity shall
1955	inform the assisted living facility of the procedures to follow
1956	should an emergent condition arise. This subsection expires
1957	October 1, 2014.
1958	(37)  The agency may seek and implement federal waivers
1959	necessary to provide for cost-effective purchasing of home
1960	health services, private duty nursing services, transportation,
1961	independent laboratory services, and durable medical equipment
1962	and supplies through competitive bidding pursuant to s. 287.057.
1963	The agency may request appropriate waivers from the federal
1964	Health Care Financing Administration in order to competitively
1965	bid such services. The agency may exclude providers not selected
1966	through the bidding process from the Medicaid provider network.
1967	(36)(38)  The agency shall enter into agreements with not-
1968	for-profit organizations based in this state for the purpose of
1969	providing vision screening. This subsection expires October 1,
1970	2014.
1971	(37)(39)(a)  The agency shall implement a Medicaid
1972	prescribed-drug spending-control program that includes the
1973	following components:
1974	1.  A Medicaid preferred drug list, which shall be a
1975	listing of cost-effective therapeutic options recommended by the
1976	Medicaid Pharmacy and Therapeutics Committee established
1977	pursuant to s. 409.91195 and adopted by the agency for each
1978	therapeutic class on the preferred drug list. At the discretion
1979	of the committee, and when feasible, the preferred drug list
1980	should include at least two products in a therapeutic class. The
1981	agency may post the preferred drug list and updates to the
1982	preferred drug list on an Internet website without following the
1983	rulemaking procedures of chapter 120. Antiretroviral agents are
1984	excluded from the preferred drug list. The agency shall also
1985	limit the amount of a prescribed drug dispensed to no more than
1986	a 34-day supply unless the drug products' smallest marketed
1987	package is greater than a 34-day supply, or the drug is
1988	determined by the agency to be a maintenance drug in which case
1989	a 100-day maximum supply may be authorized. The agency is
1990	authorized to seek any federal waivers necessary to implement
1991	these cost-control programs and to continue participation in the
1992	federal Medicaid rebate program, or alternatively to negotiate
1993	state-only manufacturer rebates. The agency may adopt rules to
1994	implement this subparagraph. The agency shall continue to
1995	provide unlimited contraceptive drugs and items. The agency must
1996	establish procedures to ensure that:
1997	a.  There is a response to a request for prior consultation
1998	by telephone or other telecommunication device within 24 hours
1999	after receipt of a request for prior consultation; and
2000	b.  A 72-hour supply of the drug prescribed is provided in
2001	an emergency or when the agency does not provide a response
2002	within 24 hours as required by sub-subparagraph a.
2003	2.  Reimbursement to pharmacies for Medicaid prescribed
2004	drugs shall be set at the lesser of: the average wholesale price
2005	(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2006	plus 4.75 percent, the federal upper limit (FUL), the state
2007	maximum allowable cost (SMAC), or the usual and customary (UAC)
2008	charge billed by the provider.
2009	3.  The agency shall develop and implement a process for
2010	managing the drug therapies of Medicaid recipients who are using
2011	significant numbers of prescribed drugs each month. The
2012	management process may include, but is not limited to,
2013	comprehensive, physician-directed medical-record reviews, claims
2014	analyses, and case evaluations to determine the medical
2015	necessity and appropriateness of a patient's treatment plan and
2016	drug therapies. The agency may contract with a private
2017	organization to provide drug-program-management services. The
2018	Medicaid drug benefit management program shall include
2019	initiatives to manage drug therapies for HIV/AIDS patients,
2020	patients using 20 or more unique prescriptions in a 180-day
2021	period, and the top 1,000 patients in annual spending. The
2022	agency shall enroll any Medicaid recipient in the drug benefit
2023	management program if he or she meets the specifications of this
2024	provision and is not enrolled in a Medicaid health maintenance
2025	organization.
2026	4.  The agency may limit the size of its pharmacy network
2027	based on need, competitive bidding, price negotiations,
2028	credentialing, or similar criteria. The agency shall give
2029	special consideration to rural areas in determining the size and
2030	location of pharmacies included in the Medicaid pharmacy
2031	network. A pharmacy credentialing process may include criteria
2032	such as a pharmacy's full-service status, location, size,
2033	patient educational programs, patient consultation, disease
2034	management services, and other characteristics. The agency may
2035	impose a moratorium on Medicaid pharmacy enrollment when it is
2036	determined that it has a sufficient number of Medicaid-
2037	participating providers. The agency must allow dispensing
2038	practitioners to participate as a part of the Medicaid pharmacy
2039	network regardless of the practitioner's proximity to any other
2040	entity that is dispensing prescription drugs under the Medicaid
2041	program. A dispensing practitioner must meet all credentialing
2042	requirements applicable to his or her practice, as determined by
2043	the agency.
2044	5.  The agency shall develop and implement a program that
2045	requires Medicaid practitioners who prescribe drugs to use a
2046	counterfeit-proof prescription pad for Medicaid prescriptions.
2047	The agency shall require the use of standardized counterfeit-
2048	proof prescription pads by Medicaid-participating prescribers or
2049	prescribers who write prescriptions for Medicaid recipients. The
2050	agency may implement the program in targeted geographic areas or
2051	statewide.
2052	6.  The agency may enter into arrangements that require
2053	manufacturers of generic drugs prescribed to Medicaid recipients
2054	to provide rebates of at least 15.1 percent of the average
2055	manufacturer price for the manufacturer's generic products.
2056	These arrangements shall require that if a generic-drug
2057	manufacturer pays federal rebates for Medicaid-reimbursed drugs
2058	at a level below 15.1 percent, the manufacturer must provide a
2059	supplemental rebate to the state in an amount necessary to
2060	achieve a 15.1-percent rebate level.
2061	7.  The agency may establish a preferred drug list as
2062	described in this subsection, and, pursuant to the establishment
2063	of such preferred drug list, it is authorized to negotiate
2064	supplemental rebates from manufacturers that are in addition to
2065	those required by Title XIX of the Social Security Act and at no
2066	less than 14 percent of the average manufacturer price as
2067	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2068	the federal or supplemental rebate, or both, equals or exceeds
2069	29 percent. There is no upper limit on the supplemental rebates
2070	the agency may negotiate. The agency may determine that specific
2071	products, brand-name or generic, are competitive at lower rebate
2072	percentages. Agreement to pay the minimum supplemental rebate
2073	percentage will guarantee a manufacturer that the Medicaid
2074	Pharmaceutical and Therapeutics Committee will consider a
2075	product for inclusion on the preferred drug list. However, a
2076	pharmaceutical manufacturer is not guaranteed placement on the
2077	preferred drug list by simply paying the minimum supplemental
2078	rebate. Agency decisions will be made on the clinical efficacy
2079	of a drug and recommendations of the Medicaid Pharmaceutical and
2080	Therapeutics Committee, as well as the price of competing
2081	products minus federal and state rebates. The agency is
2082	authorized to contract with an outside agency or contractor to
2083	conduct negotiations for supplemental rebates. For the purposes
2084	of this section, the term "supplemental rebates" means cash
2085	rebates. Effective July 1, 2004, value-added programs as a
2086	substitution for supplemental rebates are prohibited. The agency
2087	is authorized to seek any federal waivers to implement this
2088	initiative.
2089	8.  The Agency for Health Care Administration shall expand
2090	home delivery of pharmacy products. To assist Medicaid patients
2091	in securing their prescriptions and reduce program costs, the
2092	agency shall expand its current mail-order-pharmacy diabetes-
2093	supply program to include all generic and brand-name drugs used
2094	by Medicaid patients with diabetes. Medicaid recipients in the
2095	current program may obtain nondiabetes drugs on a voluntary
2096	basis. This initiative is limited to the geographic area covered
2097	by the current contract. The agency may seek and implement any
2098	federal waivers necessary to implement this subparagraph.
2099	9.  The agency shall limit to one dose per month any drug
2100	prescribed to treat erectile dysfunction.
2101	10.a.  The agency may implement a Medicaid behavioral drug
2102	management system. The agency may contract with a vendor that
2103	has experience in operating behavioral drug management systems
2104	to implement this program. The agency is authorized to seek
2105	federal waivers to implement this program.
2106	b.  The agency, in conjunction with the Department of
2107	Children and Family Services, may implement the Medicaid
2108	behavioral drug management system that is designed to improve
2109	the quality of care and behavioral health prescribing practices
2110	based on best practice guidelines, improve patient adherence to
2111	medication plans, reduce clinical risk, and lower prescribed
2112	drug costs and the rate of inappropriate spending on Medicaid
2113	behavioral drugs. The program may include the following
2114	elements:
2115	(I)  Provide for the development and adoption of best
2116	practice guidelines for behavioral health-related drugs such as
2117	antipsychotics, antidepressants, and medications for treating
2118	bipolar disorders and other behavioral conditions; translate
2119	them into practice; review behavioral health prescribers and
2120	compare their prescribing patterns to a number of indicators
2121	that are based on national standards; and determine deviations
2122	from best practice guidelines.
2123	(II)  Implement processes for providing feedback to and
2124	educating prescribers using best practice educational materials
2125	and peer-to-peer consultation.
2126	(III)  Assess Medicaid beneficiaries who are outliers in
2127	their use of behavioral health drugs with regard to the numbers
2128	and types of drugs taken, drug dosages, combination drug
2129	therapies, and other indicators of improper use of behavioral
2130	health drugs.
2131	(IV)  Alert prescribers to patients who fail to refill
2132	prescriptions in a timely fashion, are prescribed multiple same-
2133	class behavioral health drugs, and may have other potential
2134	medication problems.
2135	(V)  Track spending trends for behavioral health drugs and
2136	deviation from best practice guidelines.
2137	(VI)  Use educational and technological approaches to
2138	promote best practices, educate consumers, and train prescribers
2139	in the use of practice guidelines.
2140	(VII)  Disseminate electronic and published materials.
2141	(VIII)  Hold statewide and regional conferences.
2142	(IX)  Implement a disease management program with a model
2143	quality-based medication component for severely mentally ill
2144	individuals and emotionally disturbed children who are high
2145	users of care.
2146	11.a.  The agency shall implement a Medicaid prescription
2147	drug management system. The agency may contract with a vendor
2148	that has experience in operating prescription drug management
2149	systems in order to implement this system. Any management system
2150	that is implemented in accordance with this subparagraph must
2151	rely on cooperation between physicians and pharmacists to
2152	determine appropriate practice patterns and clinical guidelines
2153	to improve the prescribing, dispensing, and use of drugs in the
2154	Medicaid program. The agency may seek federal waivers to
2155	implement this program.
2156	b.  The drug management system must be designed to improve
2157	the quality of care and prescribing practices based on best
2158	practice guidelines, improve patient adherence to medication
2159	plans, reduce clinical risk, and lower prescribed drug costs and
2160	the rate of inappropriate spending on Medicaid prescription
2161	drugs. The program must:
2162	(I)  Provide for the development and adoption of best
2163	practice guidelines for the prescribing and use of drugs in the
2164	Medicaid program, including translating best practice guidelines
2165	into practice; reviewing prescriber patterns and comparing them
2166	to indicators that are based on national standards and practice
2167	patterns of clinical peers in their community, statewide, and
2168	nationally; and determine deviations from best practice
2169	guidelines.
2170	(II)  Implement processes for providing feedback to and
2171	educating prescribers using best practice educational materials
2172	and peer-to-peer consultation.
2173	(III)  Assess Medicaid recipients who are outliers in their
2174	use of a single or multiple prescription drugs with regard to
2175	the numbers and types of drugs taken, drug dosages, combination
2176	drug therapies, and other indicators of improper use of
2177	prescription drugs.
2178	(IV)  Alert prescribers to patients who fail to refill
2179	prescriptions in a timely fashion, are prescribed multiple drugs
2180	that may be redundant or contraindicated, or may have other
2181	potential medication problems.
2182	(V)  Track spending trends for prescription drugs and
2183	deviation from best practice guidelines.
2184	(VI)  Use educational and technological approaches to
2185	promote best practices, educate consumers, and train prescribers
2186	in the use of practice guidelines.
2187	(VII)  Disseminate electronic and published materials.
2188	(VIII)  Hold statewide and regional conferences.
2189	(IX)  Implement disease management programs in cooperation
2190	with physicians and pharmacists, along with a model quality-
2191	based medication component for individuals having chronic
2192	medical conditions.
2193	12.  The agency is authorized to contract for drug rebate
2194	administration, including, but not limited to, calculating
2195	rebate amounts, invoicing manufacturers, negotiating disputes
2196	with manufacturers, and maintaining a database of rebate
2197	collections.
2198	13.  The agency may specify the preferred daily dosing form
2199	or strength for the purpose of promoting best practices with
2200	regard to the prescribing of certain drugs as specified in the
2201	General Appropriations Act and ensuring cost-effective
2202	prescribing practices.
2203	14.  The agency may require prior authorization for
2204	Medicaid-covered prescribed drugs. The agency may, but is not
2205	required to, prior-authorize the use of a product:
2206	a.  For an indication not approved in labeling;
2207	b.  To comply with certain clinical guidelines; or
2208	c.  If the product has the potential for overuse, misuse,
2209	or abuse.
2210
2211	The agency may require the prescribing professional to provide
2212	information about the rationale and supporting medical evidence
2213	for the use of a drug. The agency may post prior authorization
2214	criteria and protocol and updates to the list of drugs that are
2215	subject to prior authorization on an Internet website without
2216	amending its rule or engaging in additional rulemaking.
2217	15.  The agency, in conjunction with the Pharmaceutical and
2218	Therapeutics Committee, may require age-related prior
2219	authorizations for certain prescribed drugs. The agency may
2220	preauthorize the use of a drug for a recipient who may not meet
2221	the age requirement or may exceed the length of therapy for use
2222	of this product as recommended by the manufacturer and approved
2223	by the Food and Drug Administration. Prior authorization may
2224	require the prescribing professional to provide information
2225	about the rationale and supporting medical evidence for the use
2226	of a drug.
2227	16.  The agency shall implement a step-therapy prior
2228	authorization approval process for medications excluded from the
2229	preferred drug list. Medications listed on the preferred drug
2230	list must be used within the previous 12 months prior to the
2231	alternative medications that are not listed. The step-therapy
2232	prior authorization may require the prescriber to use the
2233	medications of a similar drug class or for a similar medical
2234	indication unless contraindicated in the Food and Drug
2235	Administration labeling. The trial period between the specified
2236	steps may vary according to the medical indication. The step-
2237	therapy approval process shall be developed in accordance with
2238	the committee as stated in s. 409.91195(7) and (8). A drug
2239	product may be approved without meeting the step-therapy prior
2240	authorization criteria if the prescribing physician provides the
2241	agency with additional written medical or clinical documentation
2242	that the product is medically necessary because:
2243	a.  There is not a drug on the preferred drug list to treat
2244	the disease or medical condition which is an acceptable clinical
2245	alternative;
2246	b.  The alternatives have been ineffective in the treatment
2247	of the beneficiary's disease; or
2248	c.  Based on historic evidence and known characteristics of
2249	the patient and the drug, the drug is likely to be ineffective,
2250	or the number of doses have been ineffective.
2251
2252	The agency shall work with the physician to determine the best
2253	alternative for the patient. The agency may adopt rules waiving
2254	the requirements for written clinical documentation for specific
2255	drugs in limited clinical situations.
2256	17.  The agency shall implement a return and reuse program
2257	for drugs dispensed by pharmacies to institutional recipients,
2258	which includes payment of a $5 restocking fee for the
2259	implementation and operation of the program. The return and
2260	reuse program shall be implemented electronically and in a
2261	manner that promotes efficiency. The program must permit a
2262	pharmacy to exclude drugs from the program if it is not
2263	practical or cost-effective for the drug to be included and must
2264	provide for the return to inventory of drugs that cannot be
2265	credited or returned in a cost-effective manner. The agency
2266	shall determine if the program has reduced the amount of
2267	Medicaid prescription drugs which are destroyed on an annual
2268	basis and if there are additional ways to ensure more
2269	prescription drugs are not destroyed which could safely be
2270	reused. The agency's conclusion and recommendations shall be
2271	reported to the Legislature by December 1, 2005.
2272	(b)  The agency shall implement this subsection to the
2273	extent that funds are appropriated to administer the Medicaid
2274	prescribed-drug spending-control program. The agency may
2275	contract all or any part of this program to private
2276	organizations.
2277	(c)  The agency shall submit quarterly reports to the
2278	Governor, the President of the Senate, and the Speaker of the
2279	House of Representatives which must include, but need not be
2280	limited to, the progress made in implementing this subsection
2281	and its effect on Medicaid prescribed-drug expenditures.
2282	(38)(40)  Notwithstanding the provisions of chapter 287,
2283	the agency may, at its discretion, renew a contract or contracts
2284	for fiscal intermediary services one or more times for such
2285	periods as the agency may decide; however, all such renewals may
2286	not combine to exceed a total period longer than the term of the
2287	original contract.
2288	(39)(41)  The agency shall provide for the development of a
2289	demonstration project by establishment in Miami-Dade County of a
2290	long-term-care facility licensed pursuant to chapter 395 to
2291	improve access to health care for a predominantly minority,
2292	medically underserved, and medically complex population and to
2293	evaluate alternatives to nursing home care and general acute
2294	care for such population. Such project is to be located in a
2295	health care condominium and colocated with licensed facilities
2296	providing a continuum of care. The establishment of this project
2297	is not subject to the provisions of s. 408.036 or s. 408.039.
2298	This subsection expires October 1, 2013.
2299	(42)  The agency shall develop and implement a utilization
2300	management program for Medicaid-eligible recipients for the
2301	management of occupational, physical, respiratory, and speech
2302	therapies. The agency shall establish a utilization program that
2303	may require prior authorization in order to ensure medically
2304	necessary and cost-effective treatments. The program shall be
2305	operated in accordance with a federally approved waiver program
2306	or state plan amendment. The agency may seek a federal waiver or
2307	state plan amendment to implement this program. The agency may
2308	also competitively procure these services from an outside vendor
2309	on a regional or statewide basis.
2310	(40)(43)  The agency shall may contract on a prepaid or
2311	fixed-sum basis with appropriately licensed prepaid dental
2312	health plans to provide dental services. This subsection expires
2313	October 1, 2014.
2314	(41)(44)  The Agency for Health Care Administration shall
2315	ensure that any Medicaid managed care plan as defined in s.
2316	409.9122(2)(f), whether paid on a capitated basis or a shared
2317	savings basis, is cost-effective. For purposes of this
2318	subsection, the term "cost-effective" means that a network's
2319	per-member, per-month costs to the state, including, but not
2320	limited to, fee-for-service costs, administrative costs, and
2321	case-management fees, if any, must be no greater than the
2322	state's costs associated with contracts for Medicaid services
2323	established under subsection (3), which may be adjusted for
2324	health status. The agency shall conduct actuarially sound
2325	adjustments for health status in order to ensure such cost-
2326	effectiveness and shall annually publish the results on its
2327	Internet website. Contracts established pursuant to this
2328	subsection which are not cost-effective may not be renewed. This
2329	subsection expires October 1, 2014.
2330	(42)(45)  Subject to the availability of funds, the agency
2331	shall mandate a recipient's participation in a provider lock-in
2332	program, when appropriate, if a recipient is found by the agency
2333	to have used Medicaid goods or services at a frequency or amount
2334	not medically necessary, limiting the receipt of goods or
2335	services to medically necessary providers after the 21-day
2336	appeal process has ended, for a period of not less than 1 year.
2337	The lock-in programs shall include, but are not limited to,
2338	pharmacies, medical doctors, and infusion clinics. The
2339	limitation does not apply to emergency services and care
2340	provided to the recipient in a hospital emergency department.
2341	The agency shall seek any federal waivers necessary to implement
2342	this subsection. The agency shall adopt any rules necessary to
2343	comply with or administer this subsection. This subsection
2344	expires October 1, 2014.
2345	(43)(46)  The agency shall seek a federal waiver for
2346	permission to terminate the eligibility of a Medicaid recipient
2347	who has been found to have committed fraud, through judicial or
2348	administrative determination, two times in a period of 5 years.
2349	(47)  The agency shall conduct a study of available
2350	electronic systems for the purpose of verifying the identity and
2351	eligibility of a Medicaid recipient. The agency shall recommend
2352	to the Legislature a plan to implement an electronic
2353	verification system for Medicaid recipients by January 31, 2005.
2354	(44)(48)(a)  A provider is not entitled to enrollment in
2355	the Medicaid provider network. The agency may implement a
2356	Medicaid fee-for-service provider network controls, including,
2357	but not limited to, competitive procurement and provider
2358	credentialing. If a credentialing process is used, the agency
2359	may limit its provider network based upon the following
2360	considerations: beneficiary access to care, provider
2361	availability, provider quality standards and quality assurance
2362	processes, cultural competency, demographic characteristics of
2363	beneficiaries, practice standards, service wait times, provider
2364	turnover, provider licensure and accreditation history, program
2365	integrity history, peer review, Medicaid policy and billing
2366	compliance records, clinical and medical record audit findings,
2367	and such other areas that are considered necessary by the agency
2368	to ensure the integrity of the program.
2369	(b)  The agency shall limit its network of durable medical
2370	equipment and medical supply providers. For dates of service
2371	after January 1, 2009, the agency shall limit payment for
2372	durable medical equipment and supplies to providers that meet
2373	all the requirements of this paragraph.
2374	1.  Providers must be accredited by a Centers for Medicare
2375	and Medicaid Services deemed accreditation organization for
2376	suppliers of durable medical equipment, prosthetics, orthotics,
2377	and supplies. The provider must maintain accreditation and is
2378	subject to unannounced reviews by the accrediting organization.
2379	2.  Providers must provide the services or supplies
2380	directly to the Medicaid recipient or caregiver at the provider
2381	location or recipient's residence or send the supplies directly
2382	to the recipient's residence with receipt of mailed delivery.
2383	Subcontracting or consignment of the service or supply to a
2384	third party is prohibited.
2385	3.  Notwithstanding subparagraph 2., a durable medical
2386	equipment provider may store nebulizers at a physician's office
2387	for the purpose of having the physician's staff issue the
2388	equipment if it meets all of the following conditions:
2389	a.  The physician must document the medical necessity and
2390	need to prevent further deterioration of the patient's
2391	respiratory status by the timely delivery of the nebulizer in
2392	the physician's office.
2393	b.  The durable medical equipment provider must have
2394	written documentation of the competency and training by a
2395	Florida-licensed registered respiratory therapist of any durable
2396	medical equipment staff who participate in the training of
2397	physician office staff for the use of nebulizers, including
2398	cleaning, warranty, and special needs of patients.
2399	c.  The physician's office must have documented the
2400	training and competency of any staff member who initiates the
2401	delivery of nebulizers to patients. The durable medical
2402	equipment provider must maintain copies of all physician office
2403	training.
2404	d.  The physician's office must maintain inventory records
2405	of stored nebulizers, including documentation of the durable
2406	medical equipment provider source.
2407	e.  A physician contracted with a Medicaid durable medical
2408	equipment provider may not have a financial relationship with
2409	that provider or receive any financial gain from the delivery of
2410	nebulizers to patients.
2411	4.  Providers must have a physical business location and a
2412	functional landline business phone. The location must be within
2413	the state or not more than 50 miles from the Florida state line.
2414	The agency may make exceptions for providers of durable medical
2415	equipment or supplies not otherwise available from other
2416	enrolled providers located within the state.
2417	5.  Physical business locations must be clearly identified
2418	as a business that furnishes durable medical equipment or
2419	medical supplies by signage that can be read from 20 feet away.
2420	The location must be readily accessible to the public during
2421	normal, posted business hours and must operate at least 5 hours
2422	per day and at least 5 days per week, with the exception of
2423	scheduled and posted holidays. The location may not be located
2424	within or at the same numbered street address as another
2425	enrolled Medicaid durable medical equipment or medical supply
2426	provider or as an enrolled Medicaid pharmacy that is also
2427	enrolled as a durable medical equipment provider. A licensed
2428	orthotist or prosthetist that provides only orthotic or
2429	prosthetic devices as a Medicaid durable medical equipment
2430	provider is exempt from this paragraph.
2431	6.  Providers must maintain a stock of durable medical
2432	equipment and medical supplies on site that is readily available
2433	to meet the needs of the durable medical equipment business
2434	location's customers.
2435	7.  Providers must provide a surety bond of $50,000 for
2436	each provider location, up to a maximum of 5 bonds statewide or
2437	an aggregate bond of $250,000 statewide, as identified by
2438	Federal Employer Identification Number. Providers who post a
2439	statewide or an aggregate bond must identify all of their
2440	locations in any Medicaid durable medical equipment and medical
2441	supply provider enrollment application or bond renewal. Each
2442	provider location's surety bond must be renewed annually and the
2443	provider must submit proof of renewal even if the original bond
2444	is a continuous bond. A licensed orthotist or prosthetist that
2445	provides only orthotic or prosthetic devices as a Medicaid
2446	durable medical equipment provider is exempt from the provisions
2447	in this paragraph.
2448	8.  Providers must obtain a level 2 background screening,
2449	in accordance with chapter 435 and s. 408.809, for each provider
2450	employee in direct contact with or providing direct services to
2451	recipients of durable medical equipment and medical supplies in
2452	their homes. This requirement includes, but is not limited to,
2453	repair and service technicians, fitters, and delivery staff. The
2454	provider shall pay for the cost of the background screening.
2455	9.  The following providers are exempt from subparagraphs
2456	1. and 7.:
2457	a.  Durable medical equipment providers owned and operated
2458	by a government entity.
2459	b.  Durable medical equipment providers that are operating
2460	within a pharmacy that is currently enrolled as a Medicaid
2461	pharmacy provider.
2462	c.  Active, Medicaid-enrolled orthopedic physician groups,
2463	primarily owned by physicians, which provide only orthotic and
2464	prosthetic devices.
2465	(45)(49)  The agency shall contract with established
2466	minority physician networks that provide services to
2467	historically underserved minority patients. The networks must
2468	provide cost-effective Medicaid services, comply with the
2469	requirements to be a MediPass provider, and provide their
2470	primary care physicians with access to data and other management
2471	tools necessary to assist them in ensuring the appropriate use
2472	of services, including inpatient hospital services and
2473	pharmaceuticals.
2474	(a)  The agency shall provide for the development and
2475	expansion of minority physician networks in each service area to
2476	provide services to Medicaid recipients who are eligible to
2477	participate under federal law and rules.
2478	(b)  The agency shall reimburse each minority physician
2479	network as a fee-for-service provider, including the case
2480	management fee for primary care, if any, or as a capitated rate
2481	provider for Medicaid services. Any savings shall be shared with
2482	the minority physician networks pursuant to the contract.
2483	(c)  For purposes of this subsection, the term "cost-
2484	effective" means that a network's per-member, per-month costs to
2485	the state, including, but not limited to, fee-for-service costs,
2486	administrative costs, and case-management fees, if any, must be
2487	no greater than the state's costs associated with contracts for
2488	Medicaid services established under subsection (3), which shall
2489	be actuarially adjusted for case mix, model, and service area.
2490	The agency shall conduct actuarially sound audits adjusted for
2491	case mix and model in order to ensure such cost-effectiveness
2492	and shall annually publish the audit results on its Internet
2493	website. Contracts established pursuant to this subsection which
2494	are not cost-effective may not be renewed.
2495	(d)  The agency may apply for any federal waivers needed to
2496	implement this subsection.
2497
2498	This subsection expires October 1, 2014.
2499	(46)(50)  To the extent permitted by federal law and as
2500	allowed under s. 409.906, the agency shall provide reimbursement
2501	for emergency mental health care services for Medicaid
2502	recipients in crisis stabilization facilities licensed under s.
2503	394.875 as long as those services are less expensive than the
2504	same services provided in a hospital setting.
2505	(47)(51)  The agency shall work with the Agency for Persons
2506	with Disabilities to develop a home and community-based waiver
2507	to serve children and adults who are diagnosed with familial
2508	dysautonomia or Riley-Day syndrome caused by a mutation of the
2509	IKBKAP gene on chromosome 9. The agency shall seek federal
2510	waiver approval and implement the approved waiver subject to the
2511	availability of funds and any limitations provided in the
2512	General Appropriations Act. The agency may adopt rules to
2513	implement this waiver program.
2514	(48)(52)  The agency shall implement a program of all-
2515	inclusive care for children. The program of all-inclusive care
2516	for children shall be established to provide in-home hospice-
2517	like support services to children diagnosed with a life-
2518	threatening illness and enrolled in the Children's Medical
2519	Services network to reduce hospitalizations as appropriate. The
2520	agency, in consultation with the Department of Health, may
2521	implement the program of all-inclusive care for children after
2522	obtaining approval from the Centers for Medicare and Medicaid
2523	Services.
2524	(49)(53)  Before seeking an amendment to the state plan for
2525	purposes of implementing programs authorized by the Deficit
2526	Reduction Act of 2005, the agency shall notify the Legislature.
2527	Section 13.  Section 409.91207, Florida Statutes, is
2528	repealed.
2529	Section 14.  Paragraphs (e), (l), (p), (w), and (dd) of
2530	subsection (3) of section 409.91211, Florida Statutes, are
2531	amended to read:
2532	409.91211  Medicaid managed care pilot program.-
2533	(3)  The agency shall have the following powers, duties,
2534	and responsibilities with respect to the pilot program:
2535	(e)  To implement policies and guidelines for phasing in
2536	financial risk for approved provider service networks that, for
2537	purposes of this paragraph, include the Children's Medical
2538	Services Network, over the period of the waiver and the
2539	extension thereof. These policies and guidelines must include an
2540	option for a provider service network to be paid fee-for-service
2541	rates. For any provider service network established in a managed
2542	care pilot area, the option to be paid fee-for-service rates
2543	must include a savings-settlement mechanism that is consistent
2544	with s. 409.912(41)(44). This model must be converted to a risk-
2545	adjusted capitated rate by the beginning of the final year of
2546	operation under the waiver extension, and may be converted
2547	earlier at the option of the provider service network. Federally
2548	qualified health centers may be offered an opportunity to accept
2549	or decline a contract to participate in any provider network for
2550	prepaid primary care services.
2551	(l)  To implement a system that prohibits capitated managed
2552	care plans, their representatives, and providers employed by or
2553	contracted with the capitated managed care plans from recruiting
2554	persons eligible for or enrolled in Medicaid, from providing
2555	inducements to Medicaid recipients to select a particular
2556	capitated managed care plan, and from prejudicing Medicaid
2557	recipients against other capitated managed care plans. The
2558	system shall require the entity performing choice counseling to
2559	determine if the recipient has made a choice of a plan or has
2560	opted out because of duress, threats, payment to the recipient,
2561	or incentives promised to the recipient by a third party. If the
2562	choice counseling entity determines that the decision to choose
2563	a plan was unlawfully influenced or a plan violated any of the
2564	provisions of s. 409.912(20)(21), the choice counseling entity
2565	shall immediately report the violation to the agency's program
2566	integrity section for investigation. Verification of choice
2567	counseling by the recipient shall include a stipulation that the
2568	recipient acknowledges the provisions of this subsection.
2569	(p)  To implement standards for plan compliance, including,
2570	but not limited to, standards for quality assurance and
2571	performance improvement, standards for peer or professional
2572	reviews, grievance policies, and policies for maintaining
2573	program integrity. The agency shall develop a data-reporting
2574	system, seek input from managed care plans in order to establish
2575	requirements for patient-encounter reporting, and ensure that
2576	the data reported is accurate and complete.
2577	1.  In performing the duties required under this section,
2578	the agency shall work with managed care plans to establish a
2579	uniform system to measure and monitor outcomes for a recipient
2580	of Medicaid services.
2581	2.  The system shall use financial, clinical, and other
2582	criteria based on pharmacy, medical services, and other data
2583	that is related to the provision of Medicaid services,
2584	including, but not limited to:
2585	a.  The Health Plan Employer Data and Information Set
2586	(HEDIS) or measures that are similar to HEDIS.
2587	b.  Member satisfaction.
2588	c.  Provider satisfaction.
2589	d.  Report cards on plan performance and best practices.
2590	e.  Compliance with the requirements for prompt payment of
2591	claims under ss. 627.613, 641.3155, and 641.513.
2592	f.  Utilization and quality data for the purpose of
2593	ensuring access to medically necessary services, including
2594	underutilization or inappropriate denial of services.
2595	3.  The agency shall require the managed care plans that
2596	have contracted with the agency to establish a quality assurance
2597	system that incorporates the provisions of s. 409.912(26)(27)
2598	and any standards, rules, and guidelines developed by the
2599	agency.
2600	4.  The agency shall establish an encounter database in
2601	order to compile data on health services rendered by health care
2602	practitioners who provide services to patients enrolled in
2603	managed care plans in the demonstration sites. The encounter
2604	database shall:
2605	a.  Collect the following for each type of patient
2606	encounter with a health care practitioner or facility,
2607	including:
2608	(I)  The demographic characteristics of the patient.
2609	(II)  The principal, secondary, and tertiary diagnosis.
2610	(III)  The procedure performed.
2611	(IV)  The date and location where the procedure was
2612	performed.
2613	(V)  The payment for the procedure, if any.
2614	(VI)  If applicable, the health care practitioner's
2615	universal identification number.
2616	(VII)  If the health care practitioner rendering the
2617	service is a dependent practitioner, the modifiers appropriate
2618	to indicate that the service was delivered by the dependent
2619	practitioner.
2620	b.  Collect appropriate information relating to
2621	prescription drugs for each type of patient encounter.
2622	c.  Collect appropriate information related to health care
2623	costs and utilization from managed care plans participating in
2624	the demonstration sites.
2625	5.  To the extent practicable, when collecting the data the
2626	agency shall use a standardized claim form or electronic
2627	transfer system that is used by health care practitioners,
2628	facilities, and payors.
2629	6.  Health care practitioners and facilities in the
2630	demonstration sites shall electronically submit, and managed
2631	care plans participating in the demonstration sites shall
2632	electronically receive, information concerning claims payments
2633	and any other information reasonably related to the encounter
2634	database using a standard format as required by the agency.
2635	7.  The agency shall establish reasonable deadlines for
2636	phasing in the electronic transmittal of full encounter data.
2637	8.  The system must ensure that the data reported is
2638	accurate and complete.
2639	(w)  To implement procedures to minimize the risk of
2640	Medicaid fraud and abuse in all plans operating in the Medicaid
2641	managed care pilot program authorized in this section.
2642	1.  The agency shall ensure that applicable provisions of
2643	this chapter and chapters 414, 626, 641, and 932 which relate to
2644	Medicaid fraud and abuse are applied and enforced at the
2645	demonstration project sites.
2646	2.  Providers must have the certification, license, and
2647	credentials that are required by law and waiver requirements.
2648	3.  The agency shall ensure that the plan is in compliance
2649	with s. 409.912(20) and (21) and (22).
2650	4.  The agency shall require that each plan establish
2651	functions and activities governing program integrity in order to
2652	reduce the incidence of fraud and abuse. Plans must report
2653	instances of fraud and abuse pursuant to chapter 641.
2654	5.  The plan shall have written administrative and
2655	management arrangements or procedures, including a mandatory
2656	compliance plan, which are designed to guard against fraud and
2657	abuse. The plan shall designate a compliance officer who has
2658	sufficient experience in health care.
2659	6.a.  The agency shall require all managed care plan
2660	contractors in the pilot program to report all instances of
2661	suspected fraud and abuse. A failure to report instances of
2662	suspected fraud and abuse is a violation of law and subject to
2663	the penalties provided by law.
2664	b.  An instance of fraud and abuse in the managed care
2665	plan, including, but not limited to, defrauding the state health
2666	care benefit program by misrepresentation of fact in reports,
2667	claims, certifications, enrollment claims, demographic
2668	statistics, or patient-encounter data; misrepresentation of the
2669	qualifications of persons rendering health care and ancillary
2670	services; bribery and false statements relating to the delivery
2671	of health care; unfair and deceptive marketing practices; and
2672	false claims actions in the provision of managed care, is a
2673	violation of law and subject to the penalties provided by law.
2674	c.  The agency shall require that all contractors make all
2675	files and relevant billing and claims data accessible to state
2676	regulators and investigators and that all such data is linked
2677	into a unified system to ensure consistent reviews and
2678	investigations.
2679	(dd)  To implement service delivery mechanisms within a
2680	specialty plan in area 10 to provide behavioral health care
2681	services to Medicaid-eligible children whose cases are open for
2682	child welfare services in the HomeSafeNet system. These services
2683	must be coordinated with community-based care providers as
2684	specified in s. 409.1671, where available, and be sufficient to
2685	meet the developmental, behavioral, and emotional needs of these
2686	children. Children in area 10 who have an open case in the
2687	HomeSafeNet system shall be enrolled into the specialty plan.
2688	These service delivery mechanisms must be implemented no later
2689	than July 1, 2011, in AHCA area 10 in order for the children in
2690	AHCA area 10 to remain exempt from the statewide plan under s.
2691	409.912(4)(b)5.8. An administrative fee may be paid to the
2692	specialty plan for the coordination of services based on the
2693	receipt of the state share of that fee being provided through
2694	intergovernmental transfers.
2695	Section 15.  Effective October 1, 2014, section 409.91211,
2696	Florida Statutes, is repealed.
2697	Section 16.  Section 409.9122, Florida Statutes, is amended
2698	to read:
2699	409.9122  Mandatory Medicaid managed care enrollment;
2700	programs and procedures.-
2701	(1)  It is the intent of the Legislature that the MediPass
2702	program be cost-effective, provide quality health care, and
2703	improve access to health services, and that the program be
2704	statewide. This subsection expires October 1, 2014.
2705	(2)(a)  The agency shall enroll in a managed care plan or
2706	MediPass all Medicaid recipients, except those Medicaid
2707	recipients who are: in an institution; enrolled in the Medicaid
2708	medically needy program; or eligible for both Medicaid and
2709	Medicare. Upon enrollment, individuals will be able to change
2710	their managed care option during the 90-day opt out period
2711	required by federal Medicaid regulations. The agency is
2712	authorized to seek the necessary Medicaid state plan amendment
2713	to implement this policy. However, to the extent permitted by
2714	federal law, the agency may enroll in a managed care plan or
2715	MediPass a Medicaid recipient who is exempt from mandatory
2716	managed care enrollment, provided that:
2717	1.  The recipient's decision to enroll in a managed care
2718	plan or MediPass is voluntary;
2719	2.  If the recipient chooses to enroll in a managed care
2720	plan, the agency has determined that the managed care plan
2721	provides specific programs and services which address the
2722	special health needs of the recipient; and
2723	3.  The agency receives any necessary waivers from the
2724	federal Centers for Medicare and Medicaid Services.
2725
2726	The agency shall develop rules to establish policies by which
2727	exceptions to the mandatory managed care enrollment requirement
2728	may be made on a case-by-case basis. The rules shall include the
2729	specific criteria to be applied when making a determination as
2730	to whether to exempt a recipient from mandatory enrollment in a
2731	managed care plan or MediPass. School districts participating in
2732	the certified school match program pursuant to ss. 409.908(21)
2733	and 1011.70 shall be reimbursed by Medicaid, subject to the
2734	limitations of s. 1011.70(1), for a Medicaid-eligible child
2735	participating in the services as authorized in s. 1011.70, as
2736	provided for in s. 409.9071, regardless of whether the child is
2737	enrolled in MediPass or a managed care plan. Managed care plans
2738	shall make a good faith effort to execute agreements with school
2739	districts regarding the coordinated provision of services
2740	authorized under s. 1011.70. County health departments
2741	delivering school-based services pursuant to ss. 381.0056 and
2742	381.0057 shall be reimbursed by Medicaid for the federal share
2743	for a Medicaid-eligible child who receives Medicaid-covered
2744	services in a school setting, regardless of whether the child is
2745	enrolled in MediPass or a managed care plan. Managed care plans
2746	shall make a good faith effort to execute agreements with county
2747	health departments regarding the coordinated provision of
2748	services to a Medicaid-eligible child. To ensure continuity of
2749	care for Medicaid patients, the agency, the Department of
2750	Health, and the Department of Education shall develop procedures
2751	for ensuring that a student's managed care plan or MediPass
2752	provider receives information relating to services provided in
2753	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2754	(b)  A Medicaid recipient shall not be enrolled in or
2755	assigned to a managed care plan or MediPass unless the managed
2756	care plan or MediPass has complied with the quality-of-care
2757	standards specified in paragraphs (3)(a) and (b), respectively.
2758	(c)  Medicaid recipients shall have a choice of managed
2759	care plans or MediPass. The Agency for Health Care
2760	Administration, the Department of Health, the Department of
2761	Children and Family Services, and the Department of Elderly
2762	Affairs shall cooperate to ensure that each Medicaid recipient
2763	receives clear and easily understandable information that meets
2764	the following requirements:
2765	1.  Explains the concept of managed care, including
2766	MediPass.
2767	2.  Provides information on the comparative performance of
2768	managed care plans and MediPass in the areas of quality,
2769	credentialing, preventive health programs, network size and
2770	availability, and patient satisfaction.
2771	3.  Explains where additional information on each managed
2772	care plan and MediPass in the recipient's area can be obtained.
2773	4.  Explains that recipients have the right to choose their
2774	managed care coverage at the time they first enroll in Medicaid
2775	and again at regular intervals set by the agency. However, if a
2776	recipient does not choose a managed care plan or MediPass, the
2777	agency will assign the recipient to a managed care plan or
2778	MediPass according to the criteria specified in this section.
2779	5.  Explains the recipient's right to complain, file a
2780	grievance, or change managed care plans or MediPass providers if
2781	the recipient is not satisfied with the managed care plan or
2782	MediPass.
2783	(d)  The agency shall develop a mechanism for providing
2784	information to Medicaid recipients for the purpose of making a
2785	managed care plan or MediPass selection. Examples of such
2786	mechanisms may include, but not be limited to, interactive
2787	information systems, mailings, and mass marketing materials.
2788	Managed care plans and MediPass providers are prohibited from
2789	providing inducements to Medicaid recipients to select their
2790	plans or from prejudicing Medicaid recipients against other
2791	managed care plans or MediPass providers.
2792	(e)  Medicaid recipients who are already enrolled in a
2793	managed care plan or MediPass shall be offered the opportunity
2794	to change managed care plans or MediPass providers on a
2795	staggered basis, as defined by the agency. All Medicaid
2796	recipients shall have 30 days in which to make a choice of
2797	managed care plans or MediPass providers. Those Medicaid
2798	recipients who do not make a choice shall be assigned in
2799	accordance with paragraph (f). To facilitate continuity of care,
2800	for a Medicaid recipient who is also a recipient of Supplemental
2801	Security Income (SSI), prior to assigning the SSI recipient to a
2802	managed care plan or MediPass, the agency shall determine
2803	whether the SSI recipient has an ongoing relationship with a
2804	MediPass provider or managed care plan, and if so, the agency
2805	shall assign the SSI recipient to that MediPass provider or
2806	managed care plan. Those SSI recipients who do not have such a
2807	provider relationship shall be assigned to a managed care plan
2808	or MediPass provider in accordance with paragraph (f).
2809	(f)  If a Medicaid recipient does not choose a managed care
2810	plan or MediPass provider, the agency shall assign the Medicaid
2811	recipient to a managed care plan or MediPass provider. Medicaid
2812	recipients eligible for managed care plan enrollment who are
2813	subject to mandatory assignment but who fail to make a choice
2814	shall be assigned to managed care plans until an enrollment of
2815	35 percent in MediPass and 65 percent in managed care plans, of
2816	all those eligible to choose managed care, is achieved. Once
2817	this enrollment is achieved, the assignments shall be divided in
2818	order to maintain an enrollment in MediPass and managed care
2819	plans which is in a 35 percent and 65 percent proportion,
2820	respectively. Thereafter, assignment of Medicaid recipients who
2821	fail to make a choice shall be based proportionally on the
2822	preferences of recipients who have made a choice in the previous
2823	period. Such proportions shall be revised at least quarterly to
2824	reflect an update of the preferences of Medicaid recipients. The
2825	agency shall disproportionately assign Medicaid-eligible
2826	recipients who are required to but have failed to make a choice
2827	of managed care plan or MediPass, including children, and who
2828	would be assigned to the MediPass program to the children's
2829	networks as described in s. 409.912(4)(g), Children's Medical
2830	Services Network as defined in s. 391.021, exclusive provider
2831	organizations, provider service networks, minority physician
2832	networks, and pediatric emergency department diversion programs
2833	authorized by this chapter or the General Appropriations Act, in
2834	such manner as the agency deems appropriate, until the agency
2835	has determined that the networks and programs have sufficient
2836	numbers to be operated economically. For purposes of this
2837	paragraph, when referring to assignment, the term "managed care
2838	plans" includes health maintenance organizations, exclusive
2839	provider organizations, provider service networks, minority
2840	physician networks, Children's Medical Services Network, and
2841	pediatric emergency department diversion programs authorized by
2842	this chapter or the General Appropriations Act. When making
2843	assignments, the agency shall take into account the following
2844	criteria:
2845	1.  A managed care plan has sufficient network capacity to
2846	meet the need of members.
2847	2.  The managed care plan or MediPass has previously
2848	enrolled the recipient as a member, or one of the managed care
2849	plan's primary care providers or MediPass providers has
2850	previously provided health care to the recipient.
2851	3.  The agency has knowledge that the member has previously
2852	expressed a preference for a particular managed care plan or
2853	MediPass provider as indicated by Medicaid fee-for-service
2854	claims data, but has failed to make a choice.
2855	4.  The managed care plan's or MediPass primary care
2856	providers are geographically accessible to the recipient's
2857	residence.
2858	(g)  When more than one managed care plan or MediPass
2859	provider meets the criteria specified in paragraph (f), the
2860	agency shall make recipient assignments consecutively by family
2861	unit.
2862	(h)  The agency may not engage in practices that are
2863	designed to favor one managed care plan over another or that are
2864	designed to influence Medicaid recipients to enroll in MediPass
2865	rather than in a managed care plan or to enroll in a managed
2866	care plan rather than in MediPass. This subsection does not
2867	prohibit the agency from reporting on the performance of
2868	MediPass or any managed care plan, as measured by performance
2869	criteria developed by the agency.
2870	(i)  After a recipient has made his or her selection or has
2871	been enrolled in a managed care plan or MediPass, the recipient
2872	shall have 90 days to exercise the opportunity to voluntarily
2873	disenroll and select another managed care plan or MediPass.
2874	After 90 days, no further changes may be made except for good
2875	cause. Good cause includes, but is not limited to, poor quality
2876	of care, lack of access to necessary specialty services, an
2877	unreasonable delay or denial of service, or fraudulent
2878	enrollment. The agency shall develop criteria for good cause
2879	disenrollment for chronically ill and disabled populations who
2880	are assigned to managed care plans if more appropriate care is
2881	available through the MediPass program. The agency must make a
2882	determination as to whether cause exists. However, the agency
2883	may require a recipient to use the managed care plan's or
2884	MediPass grievance process prior to the agency's determination
2885	of cause, except in cases in which immediate risk of permanent
2886	damage to the recipient's health is alleged. The grievance
2887	process, when utilized, must be completed in time to permit the
2888	recipient to disenroll by the first day of the second month
2889	after the month the disenrollment request was made. If the
2890	managed care plan or MediPass, as a result of the grievance
2891	process, approves an enrollee's request to disenroll, the agency
2892	is not required to make a determination in the case. The agency
2893	must make a determination and take final action on a recipient's
2894	request so that disenrollment occurs no later than the first day
2895	of the second month after the month the request was made. If the
2896	agency fails to act within the specified timeframe, the
2897	recipient's request to disenroll is deemed to be approved as of
2898	the date agency action was required. Recipients who disagree
2899	with the agency's finding that cause does not exist for
2900	disenrollment shall be advised of their right to pursue a
2901	Medicaid fair hearing to dispute the agency's finding.
2902	(j)  The agency shall apply for a federal waiver from the
2903	Centers for Medicare and Medicaid Services to lock eligible
2904	Medicaid recipients into a managed care plan or MediPass for 12
2905	months after an open enrollment period. After 12 months'
2906	enrollment, a recipient may select another managed care plan or
2907	MediPass provider. However, nothing shall prevent a Medicaid
2908	recipient from changing primary care providers within the
2909	managed care plan or MediPass program during the 12-month
2910	period.
2911	(k)  When a Medicaid recipient does not choose a managed
2912	care plan or MediPass provider, the agency shall assign the
2913	Medicaid recipient to a managed care plan, except in those
2914	counties in which there are fewer than two managed care plans
2915	accepting Medicaid enrollees, in which case assignment shall be
2916	to a managed care plan or a MediPass provider. Medicaid
2917	recipients in counties with fewer than two managed care plans
2918	accepting Medicaid enrollees who are subject to mandatory
2919	assignment but who fail to make a choice shall be assigned to
2920	managed care plans until an enrollment of 35 percent in MediPass
2921	and 65 percent in managed care plans, of all those eligible to
2922	choose managed care, is achieved. Once that enrollment is
2923	achieved, the assignments shall be divided in order to maintain
2924	an enrollment in MediPass and managed care plans which is in a
2925	35 percent and 65 percent proportion, respectively. For purposes
2926	of this paragraph, when referring to assignment, the term
2927	"managed care plans" includes exclusive provider organizations,
2928	provider service networks, Children's Medical Services Network,
2929	minority physician networks, and pediatric emergency department
2930	diversion programs authorized by this chapter or the General
2931	Appropriations Act. When making assignments, the agency shall
2932	take into account the following criteria:
2933	1.  A managed care plan has sufficient network capacity to
2934	meet the need of members.
2935	2.  The managed care plan or MediPass has previously
2936	enrolled the recipient as a member, or one of the managed care
2937	plan's primary care providers or MediPass providers has
2938	previously provided health care to the recipient.
2939	3.  The agency has knowledge that the member has previously
2940	expressed a preference for a particular managed care plan or
2941	MediPass provider as indicated by Medicaid fee-for-service
2942	claims data, but has failed to make a choice.
2943	4.  The managed care plan's or MediPass primary care
2944	providers are geographically accessible to the recipient's
2945	residence.
2946	5.  The agency has authority to make mandatory assignments
2947	based on quality of service and performance of managed care
2948	plans.
2949	(l)  Notwithstanding the provisions of chapter 287, the
2950	agency may, at its discretion, renew cost-effective contracts
2951	for choice counseling services once or more for such periods as
2952	the agency may decide. However, all such renewals may not
2953	combine to exceed a total period longer than the term of the
2954	original contract.
2955
2956	This subsection expires October 1, 2014.
2957	(3)(a)  The agency shall establish quality-of-care
2958	standards for managed care plans. These standards shall be based
2959	upon, but are not limited to:
2960	1.  Compliance with the accreditation requirements as
2961	provided in s. 641.512.
2962	2.  Compliance with Early and Periodic Screening,
2963	Diagnosis, and Treatment screening requirements.
2964	3.  The percentage of voluntary disenrollments.
2965	4.  Immunization rates.
2966	5.  Standards of the National Committee for Quality
2967	Assurance and other approved accrediting bodies.
2968	6.  Recommendations of other authoritative bodies.
2969	7.  Specific requirements of the Medicaid program, or
2970	standards designed to specifically assist the unique needs of
2971	Medicaid recipients.
2972	8.  Compliance with the health quality improvement system
2973	as established by the agency, which incorporates standards and
2974	guidelines developed by the Medicaid Bureau of the Health Care
2975	Financing Administration as part of the quality assurance reform
2976	initiative.
2977	(b)  For the MediPass program, the agency shall establish
2978	standards which are based upon, but are not limited to:
2979	1.  Quality-of-care standards which are comparable to those
2980	required of managed care plans.
2981	2.  Credentialing standards for MediPass providers.
2982	3.  Compliance with Early and Periodic Screening,
2983	Diagnosis, and Treatment screening requirements.
2984	4.  Immunization rates.
2985	5.  Specific requirements of the Medicaid program, or
2986	standards designed to specifically assist the unique needs of
2987	Medicaid recipients.
2988
2989	This subsection expires October 1, 2014.
2990	(4)(a)  Each female recipient may select as her primary
2991	care provider an obstetrician/gynecologist who has agreed to
2992	participate as a MediPass primary care case manager.
2993	(b)  The agency shall establish a complaints and grievance
2994	process to assist Medicaid recipients enrolled in the MediPass
2995	program to resolve complaints and grievances. The agency shall
2996	investigate reports of quality-of-care grievances which remain
2997	unresolved to the satisfaction of the enrollee.
2998
2999	This subsection expires October 1, 2014.
3000	(5)(a)  The agency shall work cooperatively with the Social
3001	Security Administration to identify beneficiaries who are
3002	jointly eligible for Medicare and Medicaid and shall develop
3003	cooperative programs to encourage these beneficiaries to enroll
3004	in a Medicare participating health maintenance organization or
3005	prepaid health plans.
3006	(b)  The agency shall work cooperatively with the
3007	Department of Elderly Affairs to assess the potential cost-
3008	effectiveness of providing MediPass to beneficiaries who are
3009	jointly eligible for Medicare and Medicaid on a voluntary choice
3010	basis. If the agency determines that enrollment of these
3011	beneficiaries in MediPass has the potential for being cost-
3012	effective for the state, the agency shall offer MediPass to
3013	these beneficiaries on a voluntary choice basis in the counties
3014	where MediPass operates.
3015
3016	This subsection expires October 1, 2014.
3017	(6)  MediPass enrolled recipients may receive up to 10
3018	visits of reimbursable services by participating Medicaid
3019	physicians licensed under chapter 460 and up to four visits of
3020	reimbursable services by participating Medicaid physicians
3021	licensed under chapter 461. Any further visits must be by prior
3022	authorization by the MediPass primary care provider. However,
3023	nothing in this subsection may be construed to increase the
3024	total number of visits or the total amount of dollars per year
3025	per person under current Medicaid rules, unless otherwise
3026	provided for in the General Appropriations Act. This subsection
3027	expires October 1, 2014.
3028	(7)  The agency shall investigate the feasibility of
3029	developing managed care plan and MediPass options for the
3030	following groups of Medicaid recipients:
3031	(a)  Pregnant women and infants.
3032	(b)  Elderly and disabled recipients, especially those who
3033	are at risk of nursing home placement.
3034	(c)  Persons with developmental disabilities.
3035	(d)  Qualified Medicare beneficiaries.
3036	(e)  Adults who have chronic, high-cost medical conditions.
3037	(f)  Adults and children who have mental health problems.
3038	(g)  Other recipients for whom managed care plans and
3039	MediPass offer the opportunity of more cost-effective care and
3040	greater access to qualified providers.
3041	(8)(a)  The agency shall encourage the development of
3042	public and private partnerships to foster the growth of health
3043	maintenance organizations and prepaid health plans that will
3044	provide high-quality health care to Medicaid recipients.
3045	(b)  Subject to the availability of moneys and any
3046	limitations established by the General Appropriations Act or
3047	chapter 216, the agency is authorized to enter into contracts
3048	with traditional providers of health care to low-income persons
3049	to assist such providers with the technical aspects of
3050	cooperatively developing Medicaid prepaid health plans.
3051	1.  The agency may contract with disproportionate share
3052	hospitals, county health departments, federally initiated or
3053	federally funded community health centers, and counties that
3054	operate either a hospital or a community clinic.
3055	2.  A contract may not be for more than $100,000 per year,
3056	and no contract may be extended with any particular provider for
3057	more than 2 years. The contract is intended only as seed or
3058	development funding and requires a commitment from the
3059	interested party.
3060	3.  A contract must require participation by at least one
3061	community health clinic and one disproportionate share hospital.
3062	(7)(9)(a)  The agency shall develop and implement a
3063	comprehensive plan to ensure that recipients are adequately
3064	informed of their choices and rights under all Medicaid managed
3065	care programs and that Medicaid managed care programs meet
3066	acceptable standards of quality in patient care, patient
3067	satisfaction, and financial solvency.
3068	(b)  The agency shall provide adequate means for informing
3069	patients of their choice and rights under a managed care plan at
3070	the time of eligibility determination.
3071	(c)  The agency shall require managed care plans and
3072	MediPass providers to demonstrate and document plans and
3073	activities, as defined by rule, including outreach and followup,
3074	undertaken to ensure that Medicaid recipients receive the health
3075	care service to which they are entitled.
3076
3077	This subsection expires October 1, 2014.
3078	(8)(10)  The agency shall consult with Medicaid consumers
3079	and their representatives on an ongoing basis regarding
3080	measurements of patient satisfaction, procedures for resolving
3081	patient grievances, standards for ensuring quality of care,
3082	mechanisms for providing patient access to services, and
3083	policies affecting patient care. This subsection expires October
3084	1, 2014.
3085	(9)(11)  The agency may extend eligibility for Medicaid
3086	recipients enrolled in licensed and accredited health
3087	maintenance organizations for the duration of the enrollment
3088	period or for 6 months, whichever is earlier, provided the
3089	agency certifies that such an offer will not increase state
3090	expenditures. This subsection expires October 1, 2013.
3091	(10)(12)  A managed care plan that has a Medicaid contract
3092	shall at least annually review each primary care physician's
3093	active patient load and shall ensure that additional Medicaid
3094	recipients are not assigned to physicians who have a total
3095	active patient load of more than 3,000 patients. As used in this
3096	subsection, the term "active patient" means a patient who is
3097	seen by the same primary care physician, or by a physician
3098	assistant or advanced registered nurse practitioner under the
3099	supervision of the primary care physician, at least three times
3100	within a calendar year. Each primary care physician shall
3101	annually certify to the managed care plan whether or not his or
3102	her patient load exceeds the limits established under this
3103	subsection and the managed care plan shall accept such
3104	certification on face value as compliance with this subsection.
3105	The agency shall accept the managed care plan's representations
3106	that it is in compliance with this subsection based on the
3107	certification of its primary care physicians, unless the agency
3108	has an objective indication that access to primary care is being
3109	compromised, such as receiving complaints or grievances relating
3110	to access to care. If the agency determines that an objective
3111	indication exists that access to primary care is being
3112	compromised, it may verify the patient load certifications
3113	submitted by the managed care plan's primary care physicians and
3114	that the managed care plan is not assigning Medicaid recipients
3115	to primary care physicians who have an active patient load of
3116	more than 3,000 patients. This subsection expires October 1,
3117	2014.
3118	(11)(13)  Effective July 1, 2003, the agency shall adjust
3119	the enrollee assignment process of Medicaid managed prepaid
3120	health plans for those Medicaid managed prepaid plans operating
3121	in Miami-Dade County which have executed a contract with the
3122	agency for a minimum of 8 consecutive years in order for the
3123	Medicaid managed prepaid plan to maintain a minimum enrollment
3124	level of 15,000 members per month. When assigning enrollees
3125	pursuant to this subsection, the agency shall give priority to
3126	providers that initially qualified under this subsection until
3127	such providers reach and maintain an enrollment level of 15,000
3128	members per month. A prepaid health plan that has a statewide
3129	Medicaid enrollment of 25,000 or more members is not eligible
3130	for enrollee assignments under this subsection. This subsection
3131	expires October 1, 2014.
3132	(12)(14)  The agency shall include in its calculation of
3133	the hospital inpatient component of a Medicaid health
3134	maintenance organization's capitation rate any special payments,
3135	including, but not limited to, upper payment limit or
3136	disproportionate share hospital payments, made to qualifying
3137	hospitals through the fee-for-service program. The agency may
3138	seek federal waiver approval or state plan amendment as needed
3139	to implement this adjustment.
3140	(13)  The agency shall develop a process to enable any
3141	recipient with access to employer-sponsored health care coverage
3142	to opt out of all eligible plans in the Medicaid program and to
3143	use Medicaid financial assistance to pay for the recipient's
3144	share of cost in any such employer-sponsored coverage.
3145	Contingent on federal approval, the agency shall also enable
3146	recipients with access to other insurance or related products
3147	that provide access to health care services created pursuant to
3148	state law, including any plan or product available pursuant to
3149	the Florida Health Choices Program or any health exchange, to
3150	opt out. The amount of financial assistance provided for each
3151	recipient may not exceed the amount of the Medicaid premium that
3152	would have been paid to a plan for that recipient.
3153	(14)  The agency shall maintain and operate the Medicaid
3154	Encounter Data System to collect, process, store, and report on
3155	covered services provided to all Florida Medicaid recipients
3156	enrolled in prepaid managed care plans.
3157	(a)  Prepaid managed care plans shall submit encounter data
3158	electronically in a format that complies with the Health
3159	Insurance Portability and Accountability Act provisions for
3160	electronic claims and in accordance with deadlines established
3161	by the agency. Prepaid managed care plans must certify that the
3162	data reported is accurate and complete.
3163	(b)  The agency is responsible for validating the data
3164	submitted by the plans. The agency shall develop methods and
3165	protocols for ongoing analysis of the encounter data that
3166	adjusts for differences in characteristics of prepaid plan
3167	enrollees to allow comparison of service utilization among plans
3168	and against expected levels of use. The analysis shall be used
3169	to identify possible cases of systemic underutilization or
3170	denials of claims and inappropriate service utilization such as
3171	higher-than-expected emergency department encounters. The
3172	analysis shall provide periodic feedback to the plans and enable
3173	the agency to establish corrective action plans when necessary.
3174	One of the focus areas for the analysis shall be the use of
3175	prescription drugs.
3176	(15)  The agency may establish a per-member, per-month
3177	payment for Medicare Advantage Special Needs members that are
3178	also eligible for Medicaid as a mechanism for meeting the
3179	state's cost-sharing obligation. The agency may also develop a
3180	per-member, per-month payment only for Medicaid-covered services
3181	for which the state is responsible. The agency shall develop a
3182	mechanism to ensure that such per-member, per-month payment
3183	enhances the value to the state and enrolled members by limiting
3184	cost sharing, enhances the scope of Medicare supplemental
3185	benefits that are equal to or greater than Medicaid coverage for
3186	select services, and improves care coordination.
3187	(16)  The agency shall establish, and managed care plans
3188	shall use, a uniform method of accounting for and reporting
3189	medical and nonmedical costs. The agency shall make such
3190	information available to the public.
3191	(17)  The agency may, on a case-by-case basis, exempt a
3192	recipient from mandatory enrollment in a managed care plan when
3193	the recipient has a unique, time-limited disease or condition-
3194	related circumstance and managed care enrollment will interfere
3195	with ongoing care because the recipient's provider does not
3196	participate in the managed care plans available in the
3197	recipient's area.
3198	(18)  The agency shall contract with a single provider
3199	service network to function as a third-party administrator and
3200	managing entity for the MediPass program in all counties with
3201	fewer than two prepaid plans. The contractor may earn an
3202	administrative fee, if the fee is less than any savings
3203	determined by the reconciliation process pursuant to s.
3204	409.912(4)(d)1. This subsection expires October 1, 2014, or upon
3205	full implementation of the managed medical assistance program,
3206	whichever is sooner.
3207	Section 17.  Subsection (15) of section 430.04, Florida
3208	Statutes, is amended to read:
3209	430.04  Duties and responsibilities of the Department of
3210	Elderly Affairs.-The Department of Elderly Affairs shall:
3211	(15)  Administer all Medicaid waivers and programs relating
3212	to elders and their appropriations. The waivers include, but are
3213	not limited to:
3214	(a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3215	established in s. 430.502(7), (8), and (9).
3216	(a)(b)  The Assisted Living for the Frail Elderly Waiver.
3217	(b)(c)  The Aged and Disabled Adult Waiver.
3218	(c)(d)  The Adult Day Health Care Waiver.
3219	(d)(e)  The Consumer-Directed Care Plus Program as defined
3220	in s. 409.221.
3221	(e)(f)  The Program of All-inclusive Care for the Elderly.
3222	(f)(g)  The Long-Term Care Community-Based Diversion Pilot
3223	Project as described in s. 430.705.
3224	(g)(h)  The Channeling Services Waiver for Frail Elders.
3225
3226	The department shall develop a transition plan for recipients
3227	receiving services in long-term care Medicaid waivers for elders
3228	or disabled adults on the date eligible plans become available
3229	in each recipient's region defined in s. 409.981(2) to enroll
3230	those recipients in eligible plans. This subsection expires
3231	October 1, 2013.
3232	Section 18.  Section 430.2053, Florida Statutes, is amended
3233	to read:
3234	430.2053  Aging resource centers.-
3235	(1)  The department, in consultation with the Agency for
3236	Health Care Administration and the Department of Children and
3237	Family Services, shall develop pilot projects for aging resource
3238	centers. By October 31, 2004, the department, in consultation
3239	with the agency and the Department of Children and Family
3240	Services, shall develop an implementation plan for aging
3241	resource centers and submit the plan to the Governor, the
3242	President of the Senate, and the Speaker of the House of
3243	Representatives. The plan must include qualifications for
3244	designation as a center, the functions to be performed by each
3245	center, and a process for determining that a current area agency
3246	on aging is ready to assume the functions of an aging resource
3247	center.
3248	(2)  Each area agency on aging shall develop, in
3249	consultation with the existing community care for the elderly
3250	lead agencies within their planning and service areas, a
3251	proposal that describes the process the area agency on aging
3252	intends to undertake to transition to an aging resource center
3253	prior to July 1, 2005, and that describes the area agency's
3254	compliance with the requirements of this section. The proposals
3255	must be submitted to the department prior to December 31, 2004.
3256	The department shall evaluate all proposals for readiness and,
3257	prior to March 1, 2005, shall select three area agencies on
3258	aging which meet the requirements of this section to begin the
3259	transition to aging resource centers. Those area agencies on
3260	aging which are not selected to begin the transition to aging
3261	resource centers shall, in consultation with the department and
3262	the existing community care for the elderly lead agencies within
3263	their planning and service areas, amend their proposals as
3264	necessary and resubmit them to the department prior to July 1,
3265	2005. The department may transition additional area agencies to
3266	aging resource centers as it determines that area agencies are
3267	in compliance with the requirements of this section.
3268	(3)  The Auditor General and the Office of Program Policy
3269	Analysis and Government Accountability (OPPAGA) shall jointly
3270	review and assess the department's process for determining an
3271	area agency's readiness to transition to an aging resource
3272	center.
3273	(a)  The review must, at a minimum, address the
3274	appropriateness of the department's criteria for selection of an
3275	area agency to transition to an aging resource center, the
3276	instruments applied, the degree to which the department
3277	accurately determined each area agency's compliance with the
3278	readiness criteria, the quality of the technical assistance
3279	provided by the department to an area agency in correcting any
3280	weaknesses identified in the readiness assessment, and the
3281	degree to which each area agency overcame any identified
3282	weaknesses.
3283	(b)  Reports of these reviews must be submitted to the
3284	appropriate substantive and appropriations committees in the
3285	Senate and the House of Representatives on March 1 and September
3286	1 of each year until full transition to aging resource centers
3287	has been accomplished statewide, except that the first report
3288	must be submitted by February 1, 2005, and must address all
3289	readiness activities undertaken through December 31, 2004. The
3290	perspectives of all participants in this review process must be
3291	included in each report.
3292	(2)(4)  The purposes of an aging resource center shall be:
3293	(a)  To provide Florida's elders and their families with a
3294	locally focused, coordinated approach to integrating information
3295	and referral for all available services for elders with the
3296	eligibility determination entities for state and federally
3297	funded long-term-care services.
3298	(b)  To provide for easier access to long-term-care
3299	services by Florida's elders and their families by creating
3300	multiple access points to the long-term-care network that flow
3301	through one established entity with wide community recognition.
3302	(3)(5)  The duties of an aging resource center are to:
3303	(a)  Develop referral agreements with local community
3304	service organizations, such as senior centers, existing elder
3305	service providers, volunteer associations, and other similar
3306	organizations, to better assist clients who do not need or do
3307	not wish to enroll in programs funded by the department or the
3308	agency. The referral agreements must also include a protocol,
3309	developed and approved by the department, which provides
3310	specific actions that an aging resource center and local
3311	community service organizations must take when an elder or an
3312	elder's representative seeking information on long-term-care
3313	services contacts a local community service organization prior
3314	to contacting the aging resource center. The protocol shall be
3315	designed to ensure that elders and their families are able to
3316	access information and services in the most efficient and least
3317	cumbersome manner possible.
3318	(b)  Provide an initial screening of all clients who
3319	request long-term-care services to determine whether the person
3320	would be most appropriately served through any combination of
3321	federally funded programs, state-funded programs, locally funded
3322	or community volunteer programs, or private funding for
3323	services.
3324	(c)  Determine eligibility for the programs and services
3325	listed in subsection (9) (11) for persons residing within the
3326	geographic area served by the aging resource center and
3327	determine a priority ranking for services which is based upon
3328	the potential recipient's frailty level and likelihood of
3329	institutional placement without such services.
3330	(d)  Manage the availability of financial resources for the
3331	programs and services listed in subsection (9) (11) for persons
3332	residing within the geographic area served by the aging resource
3333	center.
3334	(e)  When financial resources become available, refer a
3335	client to the most appropriate entity to begin receiving
3336	services. The aging resource center shall make referrals to lead
3337	agencies for service provision that ensure that individuals who
3338	are vulnerable adults in need of services pursuant to s.
3339	415.104(3)(b), or who are victims of abuse, neglect, or
3340	exploitation in need of immediate services to prevent further
3341	harm and are referred by the adult protective services program,
3342	are given primary consideration for receiving community-care-
3343	for-the-elderly services in compliance with the requirements of
3344	s. 430.205(5)(a) and that other referrals for services are in
3345	compliance with s. 430.205(5)(b).
3346	(f)  Convene a work group to advise in the planning,
3347	implementation, and evaluation of the aging resource center. The
3348	work group shall be comprised of representatives of local
3349	service providers, Alzheimer's Association chapters, housing
3350	authorities, social service organizations, advocacy groups,
3351	representatives of clients receiving services through the aging
3352	resource center, and any other persons or groups as determined
3353	by the department. The aging resource center, in consultation
3354	with the work group, must develop annual program improvement
3355	plans that shall be submitted to the department for
3356	consideration. The department shall review each annual
3357	improvement plan and make recommendations on how to implement
3358	the components of the plan.
3359	(g)  Enhance the existing area agency on aging in each
3360	planning and service area by integrating, either physically or
3361	virtually, the staff and services of the area agency on aging
3362	with the staff of the department's local CARES Medicaid nursing
3363	home preadmission screening unit and a sufficient number of
3364	staff from the Department of Children and Family Services'
3365	Economic Self-Sufficiency Unit necessary to determine the
3366	financial eligibility for all persons age 60 and older residing
3367	within the area served by the aging resource center that are
3368	seeking Medicaid services, Supplemental Security Income, and
3369	food assistance.
3370	(h)  Assist clients who request long-term care services in
3371	being evaluated for eligibility for enrollment in the Medicaid
3372	long-term care managed care program as eligible plans become
3373	available in each of the regions pursuant to s. 409.981(2).
3374	(i)  Provide choice counseling for the Medicaid long-term
3375	care managed care program by integrating, either physically or
3376	virtually, choice counseling staff and services as eligible
3377	plans become available in each of the regions pursuant to s.
3378	409.981(2). Pursuant to s. 409.984(1), the agency may contract
3379	directly with the aging resource center to provide choice
3380	counseling services or may contract with another vendor if the
3381	aging resource center does not choose to provide such services.
3382	(j)  Assist Medicaid recipients enrolled in the Medicaid
3383	long-term care managed care program with informally resolving
3384	grievances with a managed care network and assist Medicaid
3385	recipients in accessing the managed care network's formal
3386	grievance process as eligible plans become available in each of
3387	the regions defined in s. 409.981(2).
3388	(4)(6)  The department shall select the entities to become
3389	aging resource centers based on each entity's readiness and
3390	ability to perform the duties listed in subsection (3) (5) and
3391	the entity's:
3392	(a)  Expertise in the needs of each target population the
3393	center proposes to serve and a thorough knowledge of the
3394	providers that serve these populations.
3395	(b)  Strong connections to service providers, volunteer
3396	agencies, and community institutions.
3397	(c)  Expertise in information and referral activities.
3398	(d)  Knowledge of long-term-care resources, including
3399	resources designed to provide services in the least restrictive
3400	setting.
3401	(e)  Financial solvency and stability.
3402	(f)  Ability to collect, monitor, and analyze data in a
3403	timely and accurate manner, along with systems that meet the
3404	department's standards.
3405	(g)  Commitment to adequate staffing by qualified personnel
3406	to effectively perform all functions.
3407	(h)  Ability to meet all performance standards established
3408	by the department.
3409	(5)(7)  The aging resource center shall have a governing
3410	body which shall be the same entity described in s. 20.41(7),
3411	and an executive director who may be the same person as
3412	described in s. 20.41(7). The governing body shall annually
3413	evaluate the performance of the executive director.
3414	(6)(8)  The aging resource center may not be a provider of
3415	direct services other than choice counseling as eligible plans
3416	become available in each of the regions defined in s.
3417	409.981(2), information and referral services, and screening.
3418	(7)(9)  The aging resource center must agree to allow the
3419	department to review any financial information the department
3420	determines is necessary for monitoring or reporting purposes,
3421	including financial relationships.
3422	(8)(10)  The duties and responsibilities of the community
3423	care for the elderly lead agencies within each area served by an
3424	aging resource center shall be to:
3425	(a)  Develop strong community partnerships to maximize the
3426	use of community resources for the purpose of assisting elders
3427	to remain in their community settings for as long as it is
3428	safely possible.
3429	(b)  Conduct comprehensive assessments of clients that have
3430	been determined eligible and develop a care plan consistent with
3431	established protocols that ensures that the unique needs of each
3432	client are met.
3433	(9)(11)  The services to be administered through the aging
3434	resource center shall include those funded by the following
3435	programs:
3436	(a)  Community care for the elderly.
3437	(b)  Home care for the elderly.
3438	(c)  Contracted services.
3439	(d)  Alzheimer's disease initiative.
3440	(e)  Aged and disabled adult Medicaid waiver. This
3441	paragraph expires October 1, 2013.
3442	(f)  Assisted living for the frail elderly Medicaid waiver.
3443	This paragraph expires October 1, 2013.
3444	(g)  Older Americans Act.
3445	(10)(12)  The department shall, prior to designation of an
3446	aging resource center, develop by rule operational and quality
3447	assurance standards and outcome measures to ensure that clients
3448	receiving services through all long-term-care programs
3449	administered through an aging resource center are receiving the
3450	appropriate care they require and that contractors and
3451	subcontractors are adhering to the terms of their contracts and
3452	are acting in the best interests of the clients they are
3453	serving, consistent with the intent of the Legislature to reduce
3454	the use of and cost of nursing home care. The department shall
3455	by rule provide operating procedures for aging resource centers,
3456	which shall include:
3457	(a)  Minimum standards for financial operation, including
3458	audit procedures.
3459	(b)  Procedures for monitoring and sanctioning of service
3460	providers.
3461	(c)  Minimum standards for technology utilized by the aging
3462	resource center.
3463	(d)  Minimum staff requirements which shall ensure that the
3464	aging resource center employs sufficient quality and quantity of
3465	staff to adequately meet the needs of the elders residing within
3466	the area served by the aging resource center.
3467	(e)  Minimum accessibility standards, including hours of
3468	operation.
3469	(f)  Minimum oversight standards for the governing body of
3470	the aging resource center to ensure its continuous involvement
3471	in, and accountability for, all matters related to the
3472	development, implementation, staffing, administration, and
3473	operations of the aging resource center.
3474	(g)  Minimum education and experience requirements for
3475	executive directors and other executive staff positions of aging
3476	resource centers.
3477	(h)  Minimum requirements regarding any executive staff
3478	positions that the aging resource center must employ and minimum
3479	requirements that a candidate must meet in order to be eligible
3480	for appointment to such positions.
3481	(11)(13)  In an area in which the department has designated
3482	an area agency on aging as an aging resource center, the
3483	department and the agency shall not make payments for the
3484	services listed in subsection (9) (11) and the Long-Term Care
3485	Community Diversion Project for such persons who were not
3486	screened and enrolled through the aging resource center. The
3487	department shall cease making payments for recipients in
3488	eligible plans as eligible plans become available in each of the
3489	regions defined in s. 409.981(2).
3490	(12)(14)  Each aging resource center shall enter into a
3491	memorandum of understanding with the department for
3492	collaboration with the CARES unit staff. The memorandum of
3493	understanding shall outline the staff person responsible for
3494	each function and shall provide the staffing levels necessary to
3495	carry out the functions of the aging resource center.
3496	(13)(15)  Each aging resource center shall enter into a
3497	memorandum of understanding with the Department of Children and
3498	Family Services for collaboration with the Economic Self-
3499	Sufficiency Unit staff. The memorandum of understanding shall
3500	outline which staff persons are responsible for which functions
3501	and shall provide the staffing levels necessary to carry out the
3502	functions of the aging resource center.
3503	(14)  As eligible plans become available in each of the
3504	regions defined in s. 409.981(2), if an aging resource center
3505	does not contract with the agency to provide Medicaid long-term
3506	care managed care choice counseling pursuant to s. 409.984(1),
3507	the aging resource center shall enter into a memorandum of
3508	understanding with the agency to coordinate staffing and
3509	collaborate with the choice counseling vendor. The memorandum of
3510	understanding shall identify the staff responsible for each
3511	function and shall provide the staffing levels necessary to
3512	carry out the functions of the aging resource center.
3513	(15)(16)  If any of the state activities described in this
3514	section are outsourced, either in part or in whole, the contract
3515	executing the outsourcing shall mandate that the contractor or
3516	its subcontractors shall, either physically or virtually,
3517	execute the provisions of the memorandum of understanding
3518	instead of the state entity whose function the contractor or
3519	subcontractor now performs.
3520	(16)(17)  In order to be eligible to begin transitioning to
3521	an aging resource center, an area agency on aging board must
3522	ensure that the area agency on aging which it oversees meets all
3523	of the minimum requirements set by law and in rule.
3524	(18)  The department shall monitor the three initial
3525	projects for aging resource centers and report on the progress
3526	of those projects to the Governor, the President of the Senate,
3527	and the Speaker of the House of Representatives by June 30,
3528	2005. The report must include an evaluation of the
3529	implementation process.
3530	(17)(19)(a)  Once an aging resource center is operational,
3531	the department, in consultation with the agency, may develop
3532	capitation rates for any of the programs administered through
3533	the aging resource center. Capitation rates for programs shall
3534	be based on the historical cost experience of the state in
3535	providing those same services to the population age 60 or older
3536	residing within each area served by an aging resource center.
3537	Each capitated rate may vary by geographic area as determined by
3538	the department.
3539	(b)  The department and the agency may determine for each
3540	area served by an aging resource center whether it is
3541	appropriate, consistent with federal and state laws and
3542	regulations, to develop and pay separate capitated rates for
3543	each program administered through the aging resource center or
3544	to develop and pay capitated rates for service packages which
3545	include more than one program or service administered through
3546	the aging resource center.
3547	(c)  Once capitation rates have been developed and
3548	certified as actuarially sound, the department and the agency
3549	may pay service providers the capitated rates for services when
3550	appropriate.
3551	(d)  The department, in consultation with the agency, shall
3552	annually reevaluate and recertify the capitation rates,
3553	adjusting forward to account for inflation, programmatic
3554	changes.
3555	(20)  The department, in consultation with the agency,
3556	shall submit to the Governor, the President of the Senate, and
3557	the Speaker of the House of Representatives, by December 1,
3558	2006, a report addressing the feasibility of administering the
3559	following services through aging resource centers beginning July
3560	1, 2007:
3561	(a)  Medicaid nursing home services.
3562	(b)  Medicaid transportation services.
3563	(c)  Medicaid hospice care services.
3564	(d)  Medicaid intermediate care services.
3565	(e)  Medicaid prescribed drug services.
3566	(f)  Medicaid assistive care services.
3567	(g)  Any other long-term-care program or Medicaid service.
3568	(18)(21)  This section shall not be construed to allow an
3569	aging resource center to restrict, manage, or impede the local
3570	fundraising activities of service providers.
3571	Section 19.  Effective October 1, 2013, sections 430.701,
3572	430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3573	430.708, and 430.709, Florida Statutes, are repealed.
3574	Section 20.  Sections 409.9301, 409.942, 409.944, 409.945,
3575	409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3576	as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3577	402.87, Florida Statutes, respectively.
3578	Section 21.  Paragraph (a) of subsection (1) of section
3579	443.111, Florida Statutes, is amended to read:
3580	443.111  Payment of benefits.-
3581	(1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3582	in accordance with rules adopted by the Agency for Workforce
3583	Innovation, subject to the following requirements:
3584	(a)  Benefits are payable by mail or electronically.
3585	Notwithstanding s. 402.84(4) s. 409.942(4), the agency may
3586	develop a system for the payment of benefits by electronic funds
3587	transfer, including, but not limited to, debit cards, electronic
3588	payment cards, or any other means of electronic payment that the
3589	agency deems to be commercially viable or cost-effective.
3590	Commodities or services related to the development of such a
3591	system shall be procured by competitive solicitation, unless
3592	they are purchased from a state term contract pursuant to s.
3593	287.056. The agency shall adopt rules necessary to administer
3594	the system.
3595	Section 22.  Subsection (4) of section 641.386, Florida
3596	Statutes, is amended to read:
3597	641.386  Agent licensing and appointment required;
3598	exceptions.-
3599	(4)  All agents and health maintenance organizations shall
3600	comply with and be subject to the applicable provisions of ss.
3601	641.309 and 409.912(20)(21), and all companies and entities
3602	appointing agents shall comply with s. 626.451, when marketing
3603	for any health maintenance organization licensed pursuant to
3604	this part, including those organizations under contract with the
3605	Agency for Health Care Administration to provide health care
3606	services to Medicaid recipients or any private entity providing
3607	health care services to Medicaid recipients pursuant to a
3608	prepaid health plan contract with the Agency for Health Care
3609	Administration.
3610	Section 23.  The Agency for Health Care Administration
3611	shall develop a plan for implementing s. 409.975(8), Florida
3612	Statutes, and shall immediately seek federal approval to
3613	implement that subsection. The plan shall include a preliminary
3614	calculation of actuarially sound rates and estimated fiscal
3615	impact.
3616	Section 24.  Except as otherwise expressly provided in this
3617	act, this act shall take effect July 1, 2011, if HB 7107 or
3618	similar legislation is adopted in the same legislative session
3619	or an extension thereof and becomes law.

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