CS/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. 409.907, F.S.; providing
41	additional requirements for provider agreements for
42	Medicare crossover providers; providing that the agency is
43	not obligated to enroll certain providers as Medicare
44	crossover providers; specifying additional requirements
45	for certain providers; providing the agency may establish
46	additional criteria for providers to promote program
47	integrity; amending s. 409.911, F.S.; providing for
48	expiration of the Medicaid Low-Income Pool Council;
49	amending s. 409.912, F.S.; providing payment requirements
50	for provider service networks; providing for the
51	expiration of various provisions relating to agency
52	contracts and agreements with certain entities on
53	specified dates to conform to the reorganization of
54	Medicaid managed care; requiring the agency to contract on
55	a prepaid or fixed-sum basis with certain prepaid dental
56	health plans; eliminating obsolete provisions and updating
57	provisions, to conform; amending ss. 409.91195 and
58	409.91196, F.S.; conforming cross-references; repealing s.
59	409.91207, F.S., relating to the medical home pilot
60	project; amending s. 409.91211, F.S.; conforming cross-
61	references; providing for future repeal of s. 409.91211,
62	F.S., relating to the Medicaid managed care pilot program;
63	amending s. 409.9122, F.S.; providing for the expiration
64	of provisions relating to mandatory enrollment in a
65	Medicaid managed care plan or MediPass on specified dates
66	to conform to the reorganization of Medicaid managed care;
67	eliminating obsolete provisions; requiring the agency to
68	develop a process to enable any recipient with access to
69	employer-sponsored coverage to opt out of eligible plans
70	in the Medicaid program; requiring the agency, contingent
71	on federal approval, to enable recipients with access to
72	other coverage or related products that provide access to
73	specified health care services to opt out of eligible
74	plans in the Medicaid program; requiring the agency to
75	maintain and operate the Medicaid Encounter Data System;
76	requiring the agency to conduct a review of encounter data
77	and publish the results of the review before adjusting
78	rates for prepaid plans; authorizing the agency to
79	establish a designated payment for specified Medicare
80	Advantage Special Needs members; authorizing the agency to
81	develop a designated payment for Medicaid-only covered
82	services for which the state is responsible; requiring the
83	agency to establish, and managed care plans to use, a
84	uniform method of accounting for and reporting medical and
85	nonmedical costs; authorizing the agency to create
86	exceptions to mandatory enrollment in managed care under
87	specified circumstances; requiring the agency to contract
88	with a provider service network to function as a third-
89	party administrator and managing entity for the MediPass
90	program; providing contract provisions; providing for the
91	expiration of such contract requirements on a specified
92	date; requiring the agency to contract with a single
93	provider service network to function as a third-party
94	administrator and managing entity for the Medically Needy
95	program; providing contract provisions; providing for the
96	expiration of such contract requirements on a specified
97	date; amending s. 430.04, F.S.; eliminating obsolete
98	provisions; requiring the Department of Elderly Affairs to
99	develop a transition plan for specified elders and
100	disabled adults receiving long-term care Medicaid services
101	when eligible plans become available; providing for
102	expiration of the plan; amending s. 430.2053, F.S.;
103	eliminating obsolete provisions; providing additional
104	duties of aging resource centers; providing an additional
105	exception to direct services that may not be provided by
106	an aging resource center; providing an expiration date for
107	certain services administered through aging resource
108	centers; providing for the cessation of specified payments
109	by the department as eligible plans become available;
110	providing for a memorandum of understanding between the
111	agency and aging resource centers under certain
112	circumstances; eliminating provisions requiring reports;
113	repealing s. 430.701, F.S., relating to legislative
114	findings and intent and approval for action relating to
115	provider enrollment levels; repealing s. 430.702, F.S.,
116	relating to the Long-Term Care Community Diversion Pilot
117	Project Act; repealing s. 430.703, F.S., relating to
118	definitions; repealing s. 430.7031, F.S., relating to the
119	nursing home transition program; repealing s. 430.704,
120	F.S., relating to evaluation of long-term care through the
121	pilot projects; repealing s. 430.705, F.S., relating to
122	implementation of long-term care community diversion pilot
123	projects; repealing s. 430.706, F.S., relating to quality
124	of care; repealing s. 430.707, F.S., relating to
125	contracts; repealing s. 430.708, F.S., relating to
126	certificate of need; repealing s. 430.709, F.S., relating
127	to reports and evaluations; renumbering ss. 409.9301,
128	409.942, 409.944, 409.945, 409.946, 409.953, and 409.9531,
129	F.S., as ss. 402.81, 402.82, 402.83, 402.84, 402.85,
130	402.86, and 402.87, F.S., respectively; amending ss.
131	443.111 and 641.386, F.S.; conforming cross-references;
132	directing the agency to develop a plan to implement the
133	enrollment of the medically needy into managed care;
134	amending s. 766.118, F.S.; providing a limitation on
135	noneconomic damages for negligence of practitioners
136	providing services and care to Medicaid recipients;
137	providing effective dates and a contingent effective date.
138
139	Be It Enacted by the Legislature of the State of Florida:
140
141	Section 1.  Section 393.0661, Florida Statutes, is amended
142	to read:
143	393.0661  Home and community-based services delivery
144	system; comprehensive redesign.-The Legislature finds that the
145	home and community-based services delivery system for persons
146	with developmental disabilities and the availability of
147	appropriated funds are two of the critical elements in making
148	services available. Therefore, it is the intent of the
149	Legislature that the Agency for Persons with Disabilities shall
150	develop and implement a comprehensive redesign of the system.
151	(1)  The redesign of the home and community-based services
152	system shall include, at a minimum, all actions necessary to
153	achieve an appropriate rate structure, client choice within a
154	specified service package, appropriate assessment strategies, an
155	efficient billing process that contains reconciliation and
156	monitoring components, and a redefined role for support
157	coordinators that avoids potential conflicts of interest and
158	ensures that family/client budgets are linked to levels of need.
159	(a)  The agency shall use an assessment instrument that the
160	agency deems to be reliable and valid, including, but not
161	limited to, the Department of Children and Family Services'
162	Individual Cost Guidelines or the agency's Questionnaire for
163	Situational Information. The agency may contract with an
164	external vendor or may use support coordinators to complete
165	client assessments if it develops sufficient safeguards and
166	training to ensure ongoing inter-rater reliability.
167	(b)  The agency, with the concurrence of the Agency for
168	Health Care Administration, may contract for the determination
169	of medical necessity and establishment of individual budgets.
170	(2)  A provider of services rendered to persons with
171	developmental disabilities pursuant to a federally approved
172	waiver shall be reimbursed according to a rate methodology based
173	upon an analysis of the expenditure history and prospective
174	costs of providers participating in the waiver program, or under
175	any other methodology developed by the Agency for Health Care
176	Administration, in consultation with the Agency for Persons with
177	Disabilities, and approved by the Federal Government in
178	accordance with the waiver.
179	(3)  The Agency for Health Care Administration, in
180	consultation with the agency, shall seek federal approval and
181	implement a four-tiered waiver system to serve eligible clients
182	through the developmental disabilities and family and supported
183	living waivers. The agency shall assign all clients receiving
184	services through the developmental disabilities waiver to a tier
185	based on the Department of Children and Family Services'
186	Individual Cost Guidelines, the agency's Questionnaire for
187	Situational Information, or another such assessment instrument
188	deemed to be valid and reliable by the agency; client
189	characteristics, including, but not limited to, age; and other
190	appropriate assessment methods.
191	(a)  Tier one is limited to clients who have service needs
192	that cannot be met in tier two, three, or four for intensive
193	medical or adaptive needs and that are essential for avoiding
194	institutionalization, or who possess behavioral problems that
195	are exceptional in intensity, duration, or frequency and present
196	a substantial risk of harm to themselves or others. Total annual
197	expenditures under tier one may not exceed $150,000 per client
198	each year, provided that expenditures for clients in tier one
199	with a documented medical necessity requiring intensive
200	behavioral residential habilitation services, intensive
201	behavioral residential habilitation services with medical needs,
202	or special medical home care, as provided in the Developmental
203	Disabilities Waiver Services Coverage and Limitations Handbook,
204	are not subject to the $150,000 limit on annual expenditures.
205	(b)  Tier two is limited to clients whose service needs
206	include a licensed residential facility and who are authorized
207	to receive a moderate level of support for standard residential
208	habilitation services or a minimal level of support for behavior
209	focus residential habilitation services, or clients in supported
210	living who receive more than 6 hours a day of in-home support
211	services. Total annual expenditures under tier two may not
212	exceed $53,625 per client each year.
213	(c)  Tier three includes, but is not limited to, clients
214	requiring residential placements, clients in independent or
215	supported living situations, and clients who live in their
216	family home. Total annual expenditures under tier three may not
217	exceed $34,125 per client each year.
218	(d)  Tier four includes individuals who were enrolled in
219	the family and supported living waiver on July 1, 2007, who
220	shall be assigned to this tier without the assessments required
221	by this section. Tier four also includes, but is not limited to,
222	clients in independent or supported living situations and
223	clients who live in their family home. Total annual expenditures
224	under tier four may not exceed $14,422 per client each year.
225	(e)  The Agency for Health Care Administration shall also
226	seek federal approval to provide a consumer-directed option for
227	persons with developmental disabilities which corresponds to the
228	funding levels in each of the waiver tiers. The agency shall
229	implement the four-tiered waiver system beginning with tiers
230	one, three, and four and followed by tier two. The agency and
231	the Agency for Health Care Administration may adopt rules
232	necessary to administer this subsection.
233	(f)  The agency shall seek federal waivers and amend
234	contracts as necessary to make changes to services defined in
235	federal waiver programs administered by the agency as follows:
236	1.  Supported living coaching services may not exceed 20
237	hours per month for persons who also receive in-home support
238	services.
239	2.  Limited support coordination services is the only type
240	of support coordination service that may be provided to persons
241	under the age of 18 who live in the family home.
242	3.  Personal care assistance services are limited to 180
243	hours per calendar month and may not include rate modifiers.
244	Additional hours may be authorized for persons who have
245	intensive physical, medical, or adaptive needs if such hours are
246	essential for avoiding institutionalization.
247	4.  Residential habilitation services are limited to 8
248	hours per day. Additional hours may be authorized for persons
249	who have intensive medical or adaptive needs and if such hours
250	are essential for avoiding institutionalization, or for persons
251	who possess behavioral problems that are exceptional in
252	intensity, duration, or frequency and present a substantial risk
253	of harming themselves or others. This restriction shall be in
254	effect until the four-tiered waiver system is fully implemented.
255	5.  Chore services, nonresidential support services, and
256	homemaker services are eliminated. The agency shall expand the
257	definition of in-home support services to allow the service
258	provider to include activities previously provided in these
259	eliminated services.
260	6.  Massage therapy, medication review, and psychological
261	assessment services are eliminated.
262	7.  The agency shall conduct supplemental cost plan reviews
263	to verify the medical necessity of authorized services for plans
264	that have increased by more than 8 percent during either of the
265	2 preceding fiscal years.
266	8.  The agency shall implement a consolidated residential
267	habilitation rate structure to increase savings to the state
268	through a more cost-effective payment method and establish
269	uniform rates for intensive behavioral residential habilitation
270	services.
271	9.  Pending federal approval, the agency may extend current
272	support plans for clients receiving services under Medicaid
273	waivers for 1 year beginning July 1, 2007, or from the date
274	approved, whichever is later. Clients who have a substantial
275	change in circumstances which threatens their health and safety
276	may be reassessed during this year in order to determine the
277	necessity for a change in their support plan.
278	10.  The agency shall develop a plan to eliminate
279	redundancies and duplications between in-home support services,
280	companion services, personal care services, and supported living
281	coaching by limiting or consolidating such services.
282	11.  The agency shall develop a plan to reduce the
283	intensity and frequency of supported employment services to
284	clients in stable employment situations who have a documented
285	history of at least 3 years' employment with the same company or
286	in the same industry.
287	(4)  The geographic differential for Miami-Dade, Broward,
288	and Palm Beach Counties for residential habilitation services
289	shall be 7.5 percent.
290	(5)  The geographic differential for Monroe County for
291	residential habilitation services shall be 20 percent.
292	(6)  Effective January 1, 2010, and except as otherwise
293	provided in this section, a client served by the home and
294	community-based services waiver or the family and supported
295	living waiver funded through the agency shall have his or her
296	cost plan adjusted to reflect the amount of expenditures for the
297	previous state fiscal year plus 5 percent if such amount is less
298	than the client's existing cost plan. The agency shall use
299	actual paid claims for services provided during the previous
300	fiscal year that are submitted by October 31 to calculate the
301	revised cost plan amount. If the client was not served for the
302	entire previous state fiscal year or there was any single change
303	in the cost plan amount of more than 5 percent during the
304	previous state fiscal year, the agency shall set the cost plan
305	amount at an estimated annualized expenditure amount plus 5
306	percent. The agency shall estimate the annualized expenditure
307	amount by calculating the average of monthly expenditures,
308	beginning in the fourth month after the client enrolled,
309	interrupted services are resumed, or the cost plan was changed
310	by more than 5 percent and ending on August 31, 2009, and
311	multiplying the average by 12. In order to determine whether a
312	client was not served for the entire year, the agency shall
313	include any interruption of a waiver-funded service or services
314	lasting at least 18 days. If at least 3 months of actual
315	expenditure data are not available to estimate annualized
316	expenditures, the agency may not rebase a cost plan pursuant to
317	this subsection. The agency may not rebase the cost plan of any
318	client who experiences a significant change in recipient
319	condition or circumstance which results in a change of more than
320	5 percent to his or her cost plan between July 1 and the date
321	that a rebased cost plan would take effect pursuant to this
322	subsection.
323	(7)  Nothing in this section or in any administrative rule
324	shall be construed to prevent or limit the Agency for Health
325	Care Administration, in consultation with the Agency for Persons
326	with Disabilities, from adjusting fees, reimbursement rates,
327	lengths of stay, number of visits, or number of services, or
328	from limiting enrollment, or making any other adjustment
329	necessary to comply with the availability of moneys and any
330	limitations or directions provided for in the General
331	Appropriations Act.
332	(8)  The Agency for Persons with Disabilities shall submit
333	quarterly status reports to the Executive Office of the
334	Governor, the chair of the Senate Ways and Means Committee or
335	its successor, and the chair of the House Fiscal Council or its
336	successor regarding the financial status of home and community-
337	based services, including the number of enrolled individuals who
338	are receiving services through one or more programs; the number
339	of individuals who have requested services who are not enrolled
340	but who are receiving services through one or more programs,
341	with a description indicating the programs from which the
342	individual is receiving services; the number of individuals who
343	have refused an offer of services but who choose to remain on
344	the list of individuals waiting for services; the number of
345	individuals who have requested services but who are receiving no
346	services; a frequency distribution indicating the length of time
347	individuals have been waiting for services; and information
348	concerning the actual and projected costs compared to the amount
349	of the appropriation available to the program and any projected
350	surpluses or deficits. If at any time an analysis by the agency,
351	in consultation with the Agency for Health Care Administration,
352	indicates that the cost of services is expected to exceed the
353	amount appropriated, the agency shall submit a plan in
354	accordance with subsection (7) to the Executive Office of the
355	Governor, the chair of the Senate Ways and Means Committee or
356	its successor, and the chair of the House Fiscal Council or its
357	successor to remain within the amount appropriated. The agency
358	shall work with the Agency for Health Care Administration to
359	implement the plan so as to remain within the appropriation.
360	(9)  The agency shall develop a transition plan for
361	recipients who are receiving services in one of the four waiver
362	tiers at the time eligible managed care plans are available in
363	each recipient's region as defined in s. 409.989 to enroll those
364	recipients in eligible plans.
365	(10)  This section expires October 1, 2016.
366	Section 2.  Section 393.0662, Florida Statutes, is amended
367	to read:
368	393.0662  Individual budgets for delivery of home and
369	community-based services; iBudget system established.-The
370	Legislature finds that improved financial management of the
371	existing home and community-based Medicaid waiver program is
372	necessary to avoid deficits that impede the provision of
373	services to individuals who are on the waiting list for
374	enrollment in the program. The Legislature further finds that
375	clients and their families should have greater flexibility to
376	choose the services that best allow them to live in their
377	community within the limits of an established budget. Therefore,
378	the Legislature intends that the agency, in consultation with
379	the Agency for Health Care Administration, develop and implement
380	a comprehensive redesign of the service delivery system using
381	individual budgets as the basis for allocating the funds
382	appropriated for the home and community-based services Medicaid
383	waiver program among eligible enrolled clients. The service
384	delivery system that uses individual budgets shall be called the
385	iBudget system.
386	(1)  The agency shall establish an individual budget,
387	referred to as an iBudget, for each individual served by the
388	home and community-based services Medicaid waiver program. The
389	funds appropriated to the agency shall be allocated through the
390	iBudget system to eligible, Medicaid-enrolled clients. The
391	iBudget system shall be designed to provide for: enhanced client
392	choice within a specified service package; appropriate
393	assessment strategies; an efficient consumer budgeting and
394	billing process that includes reconciliation and monitoring
395	components; a redefined role for support coordinators that
396	avoids potential conflicts of interest; a flexible and
397	streamlined service review process; and a methodology and
398	process that ensures the equitable allocation of available funds
399	to each client based on the client's level of need, as
400	determined by the variables in the allocation algorithm.
401	(a)  In developing each client's iBudget, the agency shall
402	use an allocation algorithm and methodology. The algorithm shall
403	use variables that have been determined by the agency to have a
404	statistically validated relationship to the client's level of
405	need for services provided through the home and community-based
406	services Medicaid waiver program. The algorithm and methodology
407	may consider individual characteristics, including, but not
408	limited to, a client's age and living situation, information
409	from a formal assessment instrument that the agency determines
410	is valid and reliable, and information from other assessment
411	processes.
412	(b)  The allocation methodology shall provide the algorithm
413	that determines the amount of funds allocated to a client's
414	iBudget. The agency may approve an increase in the amount of
415	funds allocated, as determined by the algorithm, based on the
416	client having one or more of the following needs that cannot be
417	accommodated within the funding as determined by the algorithm
418	and having no other resources, supports, or services available
419	to meet the need:
420	1.  An extraordinary need that would place the health and
421	safety of the client, the client's caregiver, or the public in
422	immediate, serious jeopardy unless the increase is approved. An
423	extraordinary need may include, but is not limited to:
424	a.  A documented history of significant, potentially life-
425	threatening behaviors, such as recent attempts at suicide,
426	arson, nonconsensual sexual behavior, or self-injurious behavior
427	requiring medical attention;
428	b.  A complex medical condition that requires active
429	intervention by a licensed nurse on an ongoing basis that cannot
430	be taught or delegated to a nonlicensed person;
431	c.  A chronic comorbid condition. As used in this
432	subparagraph, the term "comorbid condition" means a medical
433	condition existing simultaneously but independently with another
434	medical condition in a patient; or
435	d.  A need for total physical assistance with activities
436	such as eating, bathing, toileting, grooming, and personal
437	hygiene.
438
439	However, the presence of an extraordinary need alone does not
440	warrant an increase in the amount of funds allocated to a
441	client's iBudget as determined by the algorithm.
442	2.  A significant need for one-time or temporary support or
443	services that, if not provided, would place the health and
444	safety of the client, the client's caregiver, or the public in
445	serious jeopardy, unless the increase is approved. A significant
446	need may include, but is not limited to, the provision of
447	environmental modifications, durable medical equipment, services
448	to address the temporary loss of support from a caregiver, or
449	special services or treatment for a serious temporary condition
450	when the service or treatment is expected to ameliorate the
451	underlying condition. As used in this subparagraph, the term
452	"temporary" means a period of fewer than 12 continuous months.
453	However, the presence of such significant need for one-time or
454	temporary supports or services alone does not warrant an
455	increase in the amount of funds allocated to a client's iBudget
456	as determined by the algorithm.
457	3.  A significant increase in the need for services after
458	the beginning of the service plan year that would place the
459	health and safety of the client, the client's caregiver, or the
460	public in serious jeopardy because of substantial changes in the
461	client's circumstances, including, but not limited to, permanent
462	or long-term loss or incapacity of a caregiver, loss of services
463	authorized under the state Medicaid plan due to a change in age,
464	or a significant change in medical or functional status which
465	requires the provision of additional services on a permanent or
466	long-term basis that cannot be accommodated within the client's
467	current iBudget. As used in this subparagraph, the term "long-
468	term" means a period of 12 or more continuous months. However,
469	such significant increase in need for services of a permanent or
470	long-term nature alone does not warrant an increase in the
471	amount of funds allocated to a client's iBudget as determined by
472	the algorithm.
473
474	The agency shall reserve portions of the appropriation for the
475	home and community-based services Medicaid waiver program for
476	adjustments required pursuant to this paragraph and may use the
477	services of an independent actuary in determining the amount of
478	the portions to be reserved.
479	(c)  A client's iBudget shall be the total of the amount
480	determined by the algorithm and any additional funding provided
481	pursuant to paragraph (b). A client's annual expenditures for
482	home and community-based services Medicaid waiver services may
483	not exceed the limits of his or her iBudget. The total of all
484	clients' projected annual iBudget expenditures may not exceed
485	the agency's appropriation for waiver services.
486	(2)  The Agency for Health Care Administration, in
487	consultation with the agency, shall seek federal approval to
488	amend current waivers, request a new waiver, and amend contracts
489	as necessary to implement the iBudget system to serve eligible,
490	enrolled clients through the home and community-based services
491	Medicaid waiver program and the Consumer-Directed Care Plus
492	Program.
493	(3)  The agency shall transition all eligible, enrolled
494	clients to the iBudget system. The agency may gradually phase in
495	the iBudget system and must complete the phase in by January 1,
496	2015.
497	(a)  While the agency phases in the iBudget system, the
498	agency may continue to serve eligible, enrolled clients under
499	the four-tiered waiver system established under s. 393.065 while
500	those clients await transitioning to the iBudget system.
501	(b)  The agency shall design the phase-in process to ensure
502	that a client does not experience more than one-half of any
503	expected overall increase or decrease to his or her existing
504	annualized cost plan during the first year that the client is
505	provided an iBudget due solely to the transition to the iBudget
506	system.
507	(4)  A client must use all available services authorized
508	under the state Medicaid plan, school-based services, private
509	insurance and other benefits, and any other resources that may
510	be available to the client before using funds from his or her
511	iBudget to pay for support and services.
512	(5)  The service limitations in s. 393.0661(3)(f)1., 2.,
513	and 3. do not apply to the iBudget system.
514	(6)  Rates for any or all services established under rules
515	of the Agency for Health Care Administration shall be designated
516	as the maximum rather than a fixed amount for individuals who
517	receive an iBudget, except for services specifically identified
518	in those rules that the agency determines are not appropriate
519	for negotiation, which may include, but are not limited to,
520	residential habilitation services.
521	(7)  The agency shall ensure that clients and caregivers
522	have access to training and education to inform them about the
523	iBudget system and enhance their ability for self-direction.
524	Such training shall be offered in a variety of formats and at a
525	minimum shall address the policies and processes of the iBudget
526	system; the roles and responsibilities of consumers, caregivers,
527	waiver support coordinators, providers, and the agency;
528	information available to help the client make decisions
529	regarding the iBudget system; and examples of support and
530	resources available in the community.
531	(8)  The agency shall collect data to evaluate the
532	implementation and outcomes of the iBudget system.
533	(9)  The agency and the Agency for Health Care
534	Administration may adopt rules specifying the allocation
535	algorithm and methodology; criteria and processes for clients to
536	access reserved funds for extraordinary needs, temporarily or
537	permanently changed needs, and one-time needs; and processes and
538	requirements for selection and review of services, development
539	of support and cost plans, and management of the iBudget system
540	as needed to administer this section.
541	(10)  The agency shall develop a transition plan for
542	recipients who are receiving services through the iBudget system
543	at the time eligible managed care plans are available in each
544	recipient's region defined in s. 409.989 to enroll those
545	recipients in eligible plans.
546	(11)  This section expires October 1, 2016.
547	Section 3.  Paragraph (e) of subsection (1) of section
548	408.040, Florida Statutes, is redesignated as paragraph (d), and
549	paragraph (b) and present paragraph (d) of that subsection are
550	amended to read:
551	408.040  Conditions and monitoring.-
552	(1)
553	(b)  The agency may consider, in addition to the other
554	criteria specified in s. 408.035, a statement of intent by the
555	applicant that a specified percentage of the annual patient days
556	at the facility will be utilized by patients eligible for care
557	under Title XIX of the Social Security Act. Any certificate of
558	need issued to a nursing home in reliance upon an applicant's
559	statements that a specified percentage of annual patient days
560	will be utilized by residents eligible for care under Title XIX
561	of the Social Security Act must include a statement that such
562	certification is a condition of issuance of the certificate of
563	need. The certificate-of-need program shall notify the Medicaid
564	program office and the Department of Elderly Affairs when it
565	imposes conditions as authorized in this paragraph in an area in
566	which a community diversion pilot project is implemented.
567	Effective July 1, 2012, the agency may not consider, or impose
568	conditions or sanctions related to, patient day utilization by
569	patients eligible for care under Title XIX the Social Security
570	Act in making certificate-of-need determinations for nursing
571	homes.
572	(d)  If a nursing home is located in a county in which a
573	long-term care community diversion pilot project has been
574	implemented under s. 430.705 or in a county in which an
575	integrated, fixed-payment delivery program for Medicaid
576	recipients who are 60 years of age or older or dually eligible
577	for Medicare and Medicaid has been implemented under s.
578	409.912(5), the nursing home may request a reduction in the
579	percentage of annual patient days used by residents who are
580	eligible for care under Title XIX of the Social Security Act,
581	which is a condition of the nursing home's certificate of need.
582	The agency shall automatically grant the nursing home's request
583	if the reduction is not more than 15 percent of the nursing
584	home's annual Medicaid-patient-days condition. A nursing home
585	may submit only one request every 2 years for an automatic
586	reduction. A requesting nursing home must notify the agency in
587	writing at least 60 days in advance of its intent to reduce its
588	annual Medicaid-patient-days condition by not more than 15
589	percent. The agency must acknowledge the request in writing and
590	must change its records to reflect the revised certificate-of-
591	need condition. This paragraph expires June 30, 2011.
592	Section 4.  Subsection (1) of section 408.0435, Florida
593	Statutes, is amended to read:
594	408.0435  Moratorium on nursing home certificates of need.-
595	(1)  Notwithstanding the establishment of need as provided
596	for in this chapter, a certificate of need for additional
597	community nursing home beds may not be approved by the agency
598	until Medicaid managed care is implemented statewide pursuant to
599	ss. 409.961-409.992 or October 1, 2016, whichever is earlier
600	July 1, 2011.
601	Section 5.  Sections 409.016 through 409.803, Florida
602	Statutes, are designated as part I of chapter 409, Florida
603	Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
604	Section 6.  Sections 409.810 through 409.821, Florida
605	Statutes, are designated as part II of chapter 409, Florida
606	Statutes, and entitled "KIDCARE."
607	Section 7.  Sections 409.901 through 409.9205, Florida
608	Statutes, are designated as part III of chapter 409, Florida
609	Statutes, and entitled "MEDICAID."
610	Section 8.  Paragraph (c) of subsection (5) of section
611	409.905, Florida Statutes, is amended, and paragraph (g) is
612	added that subsection, to read:
613	409.905  Mandatory Medicaid services.-The agency may make
614	payments for the following services, which are required of the
615	state by Title XIX of the Social Security Act, furnished by
616	Medicaid providers to recipients who are determined to be
617	eligible on the dates on which the services were provided. Any
618	service under this section shall be provided only when medically
619	necessary and in accordance with state and federal law.
620	Mandatory services rendered by providers in mobile units to
621	Medicaid recipients may be restricted by the agency. Nothing in
622	this section shall be construed to prevent or limit the agency
623	from adjusting fees, reimbursement rates, lengths of stay,
624	number of visits, number of services, or any other adjustments
625	necessary to comply with the availability of moneys and any
626	limitations or directions provided for in the General
627	Appropriations Act or chapter 216.
628	(5)  HOSPITAL INPATIENT SERVICES.-The agency shall pay for
629	all covered services provided for the medical care and treatment
630	of a recipient who is admitted as an inpatient by a licensed
631	physician or dentist to a hospital licensed under part I of
632	chapter 395. However, the agency shall limit the payment for
633	inpatient hospital services for a Medicaid recipient 21 years of
634	age or older to 45 days or the number of days necessary to
635	comply with the General Appropriations Act.
636	(c)  The agency shall implement a methodology for
637	establishing base reimbursement rates for each hospital based on
638	allowable costs, as defined by the agency. Rates shall be
639	calculated annually and take effect July 1 of each year based on
640	the most recent complete and accurate cost report submitted by
641	each hospital. Adjustments may not be made to the rates after
642	September 30 of the state fiscal year in which the rate takes
643	effect. Errors in cost reporting or calculation of rates
644	discovered after September 30 must be reconciled in a subsequent
645	rate period. The agency may not make any adjustment to a
646	hospital's reimbursement rate more than 5 years after a hospital
647	is notified of an audited rate established by the agency. The
648	requirement that the agency may not make any adjustment to a
649	hospital's reimbursement rate more than 5 years after a hospital
650	is notified of an audited rate established by the agency is
651	remedial and shall apply to actions by providers involving
652	Medicaid claims for hospital services. Hospital rates shall be
653	subject to such limits or ceilings as may be established in law
654	or described in the agency's hospital reimbursement plan.
655	Specific exemptions to the limits or ceilings may be provided in
656	the General Appropriations Act. The agency shall adjust a
657	hospital's current inpatient per diem rate to reflect the cost
658	of serving the Medicaid population at that institution if:
659	1.  The hospital experiences an increase in Medicaid
660	caseload by more than 25 percent in any year, primarily
661	resulting from the closure of a hospital in the same service
662	area occurring after July 1, 1995;
663	2.  The hospital's Medicaid per diem rate is at least 25
664	percent below the Medicaid per patient cost for that year; or
665	3.  The hospital is located in a county that has six or
666	fewer general acute care hospitals, began offering obstetrical
667	services on or after September 1999, and has submitted a request
668	in writing to the agency for a rate adjustment after July 1,
669	2000, but before September 30, 2000, in which case such
670	hospital's Medicaid inpatient per diem rate shall be adjusted to
671	cost, effective July 1, 2002.
672
673	By October 1 of each year, the agency must provide estimated
674	costs for any adjustment in a hospital inpatient per diem rate
675	to the Executive Office of the Governor, the House of
676	Representatives General Appropriations Committee, and the Senate
677	Appropriations Committee. Before the agency implements a change
678	in a hospital's inpatient per diem rate pursuant to this
679	paragraph, the Legislature must have specifically appropriated
680	sufficient funds in the General Appropriations Act to support
681	the increase in cost as estimated by the agency.
682	(g)  The agency shall develop a plan to convert inpatient
683	hospital rates to a prospective payment system that categorizes
684	each case into diagnosis-related groups (DRG) and assigns a
685	payment weight based on the average resources used to treat
686	Medicaid patients in that DRG. To the extent possible, the
687	agency shall propose an adaptation of an existing prospective
688	payment system, such as the one used by Medicare, and shall
689	propose such adjustments as are necessary for the Medicaid
690	population and to maintain budget neutrality for inpatient
691	hospital expenditures. The agency shall submit the Medicaid DRG
692	plan, identifying all steps necessary for the transition and any
693	costs associated with plan implementation, to the Governor, the
694	President of the Senate, and the Speaker of the House of
695	Representatives no later than January 1, 2013.
696	Section 9.  Paragraphs (d) and (e) of subsection (5) of
697	section 409.907, Florida Statutes, are amended to read:
698	409.907  Medicaid provider agreements.-The agency may make
699	payments for medical assistance and related services rendered to
700	Medicaid recipients only to an individual or entity who has a
701	provider agreement in effect with the agency, who is performing
702	services or supplying goods in accordance with federal, state,
703	and local law, and who agrees that no person shall, on the
704	grounds of handicap, race, color, or national origin, or for any
705	other reason, be subjected to discrimination under any program
706	or activity for which the provider receives payment from the
707	agency.
708	(5)  The agency:
709	(d)  May enroll entities as Medicare crossover-only
710	providers for payment and claims processing purposes only. The
711	provider agreement shall:
712	1.  Require that the provider be able to demonstrate to the
713	satisfaction of the agency that the provider is an eligible
714	Medicare provider and has a current provider agreement in place
715	with the Centers for Medicare and Medicaid Services.
716	2.  Require the provider to notify the agency immediately
717	in writing upon being suspended or disenrolled as a Medicare
718	provider. If the provider does not provide such notification
719	within 5 business days after suspension or disenrollment,
720	sanctions may be imposed pursuant to this chapter and the
721	provider may be required to return funds paid to the provider
722	during the period of time that the provider was suspended or
723	disenrolled as a Medicare provider.
724	3.  Require the applicant to submit an attestation, as
725	approved by the agency, that the provider meets the requirements
726	of Florida Medicaid provider enrollment criteria.
727	4.  Require the applicant to submit fingerprints as
728	required by the agency.
729	5.3.  Require that all records pertaining to health care
730	services provided to each of the provider's recipients be kept
731	for a minimum of 6 years. The agreement shall also require that
732	records and any information relating to payments claimed by the
733	provider for services under the agreement be delivered to the
734	agency or the Office of the Attorney General Medicaid Fraud
735	Control Unit when requested. If a provider does not provide such
736	records and information when requested, sanctions may be imposed
737	pursuant to this chapter.
738	6.4.  Disclose that the agreement is for the purposes of
739	paying and processing Medicare crossover claims only.
740
741	This paragraph pertains solely to Medicare crossover-only
742	providers. In order to become a standard Medicaid provider, the
743	requirements of this section and applicable rules must be met.
744	This paragraph does not create an entitlement or obligation of
745	the agency to enroll all Medicare providers that may be
746	considered a Medicare crossover-only provider in the Medicaid
747	program.
748	(e)  Providers that are required to post a surety bond as
749	part of the Medicaid enrollment process are excluded for
750	enrollment under paragraph (d) and must complete a full Medicaid
751	application. The agency may establish additional criteria to
752	promote program integrity.
753	Section 10.  Subsection (10) of section 409.911, Florida
754	Statutes, is amended to read:
755	409.911  Disproportionate share program.-Subject to
756	specific allocations established within the General
757	Appropriations Act and any limitations established pursuant to
758	chapter 216, the agency shall distribute, pursuant to this
759	section, moneys to hospitals providing a disproportionate share
760	of Medicaid or charity care services by making quarterly
761	Medicaid payments as required. Notwithstanding the provisions of
762	s. 409.915, counties are exempt from contributing toward the
763	cost of this special reimbursement for hospitals serving a
764	disproportionate share of low-income patients.
765	(10)  The Agency for Health Care Administration shall
766	create a Medicaid Low-Income Pool Council by July 1, 2006. The
767	Low-Income Pool Council shall consist of 24 members, including 2
768	members appointed by the President of the Senate, 2 members
769	appointed by the Speaker of the House of Representatives, 3
770	representatives of statutory teaching hospitals, 3
771	representatives of public hospitals, 3 representatives of
772	nonprofit hospitals, 3 representatives of for-profit hospitals,
773	2 representatives of rural hospitals, 2 representatives of units
774	of local government which contribute funding, 1 representative
775	of family practice teaching hospitals, 1 representative of
776	federally qualified health centers, 1 representative from the
777	Department of Health, and 1 nonvoting representative of the
778	Agency for Health Care Administration who shall serve as chair
779	of the council. Except for a full-time employee of a public
780	entity, an individual who qualifies as a lobbyist under s.
781	11.045 or s. 112.3215 may not serve as a member of the council.
782	Of the members appointed by the Senate President, only one shall
783	be a physician. Of the members appointed by the Speaker of the
784	House of Representatives, only one shall be a physician. The
785	physician member appointed by the Senate President and the
786	physician member appointed by the Speaker of the House of
787	Representatives must be physicians who routinely take calls in a
788	trauma center, as defined in s. 395.4001, or a hospital
789	emergency department. The council shall:
790	(a)  Make recommendations on the financing of the low-
791	income pool and the disproportionate share hospital program and
792	the distribution of their funds.
793	(b)  Advise the Agency for Health Care Administration on
794	the development of the low-income pool plan required by the
795	federal Centers for Medicare and Medicaid Services pursuant to
796	the Medicaid reform waiver.
797	(c)  Advise the Agency for Health Care Administration on
798	the distribution of hospital funds used to adjust inpatient
799	hospital rates, rebase rates, or otherwise exempt hospitals from
800	reimbursement limits as financed by intergovernmental transfers.
801	(d)  Submit its findings and recommendations to the
802	Governor and the Legislature no later than February 1 of each
803	year.
804
805	This subsection expires October 1, 2014.
806	Section 11.  Subsection (4) of section 409.91195, Florida
807	Statutes, is amended to read:
808	409.91195  Medicaid Pharmaceutical and Therapeutics
809	Committee.-There is created a Medicaid Pharmaceutical and
810	Therapeutics Committee within the agency for the purpose of
811	developing a Medicaid preferred drug list.
812	(4)  Upon recommendation of the committee, the agency shall
813	adopt a preferred drug list as described in s. 409.912(37)(39).
814	To the extent feasible, the committee shall review all drug
815	classes included on the preferred drug list every 12 months, and
816	may recommend additions to and deletions from the preferred drug
817	list, such that the preferred drug list provides for medically
818	appropriate drug therapies for Medicaid patients which achieve
819	cost savings contained in the General Appropriations Act.
820	Section 12.  Subsection (1) of section 409.91196, Florida
821	Statutes, is amended to read:
822	409.91196  Supplemental rebate agreements; public records
823	and public meetings exemption.-
824	(1)  The rebate amount, percent of rebate, manufacturer's
825	pricing, and supplemental rebate, and other trade secrets as
826	defined in s. 688.002 that the agency has identified for use in
827	negotiations, held by the Agency for Health Care Administration
828	under s. 409.912(37)(39)(a)7. are confidential and exempt from
829	s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
830	Section 13.  Section 409.912, Florida Statutes, is amended
831	to read:
832	409.912  Cost-effective purchasing of health care.-The
833	agency shall purchase goods and services for Medicaid recipients
834	in the most cost-effective manner consistent with the delivery
835	of quality medical care. To ensure that medical services are
836	effectively utilized, the agency may, in any case, require a
837	confirmation or second physician's opinion of the correct
838	diagnosis for purposes of authorizing future services under the
839	Medicaid program. This section does not restrict access to
840	emergency services or poststabilization care services as defined
841	in 42 C.F.R. part 438.114. Such confirmation or second opinion
842	shall be rendered in a manner approved by the agency. The agency
843	shall maximize the use of prepaid per capita and prepaid
844	aggregate fixed-sum basis services when appropriate and other
845	alternative service delivery and reimbursement methodologies,
846	including competitive bidding pursuant to s. 287.057, designed
847	to facilitate the cost-effective purchase of a case-managed
848	continuum of care. The agency shall also require providers to
849	minimize the exposure of recipients to the need for acute
850	inpatient, custodial, and other institutional care and the
851	inappropriate or unnecessary use of high-cost services. The
852	agency shall contract with a vendor to monitor and evaluate the
853	clinical practice patterns of providers in order to identify
854	trends that are outside the normal practice patterns of a
855	provider's professional peers or the national guidelines of a
856	provider's professional association. The vendor must be able to
857	provide information and counseling to a provider whose practice
858	patterns are outside the norms, in consultation with the agency,
859	to improve patient care and reduce inappropriate utilization.
860	The agency may mandate prior authorization, drug therapy
861	management, or disease management participation for certain
862	populations of Medicaid beneficiaries, certain drug classes, or
863	particular drugs to prevent fraud, abuse, overuse, and possible
864	dangerous drug interactions. The Pharmaceutical and Therapeutics
865	Committee shall make recommendations to the agency on drugs for
866	which prior authorization is required. The agency shall inform
867	the Pharmaceutical and Therapeutics Committee of its decisions
868	regarding drugs subject to prior authorization. The agency is
869	authorized to limit the entities it contracts with or enrolls as
870	Medicaid providers by developing a provider network through
871	provider credentialing. The agency may competitively bid single-
872	source-provider contracts if procurement of goods or services
873	results in demonstrated cost savings to the state without
874	limiting access to care. The agency may limit its network based
875	on the assessment of beneficiary access to care, provider
876	availability, provider quality standards, time and distance
877	standards for access to care, the cultural competence of the
878	provider network, demographic characteristics of Medicaid
879	beneficiaries, practice and provider-to-beneficiary standards,
880	appointment wait times, beneficiary use of services, provider
881	turnover, provider profiling, provider licensure history,
882	previous program integrity investigations and findings, peer
883	review, provider Medicaid policy and billing compliance records,
884	clinical and medical record audits, and other factors. Providers
885	are shall not be entitled to enrollment in the Medicaid provider
886	network. The agency shall determine instances in which allowing
887	Medicaid beneficiaries to purchase durable medical equipment and
888	other goods is less expensive to the Medicaid program than long-
889	term rental of the equipment or goods. The agency may establish
890	rules to facilitate purchases in lieu of long-term rentals in
891	order to protect against fraud and abuse in the Medicaid program
892	as defined in s. 409.913. The agency may seek federal waivers
893	necessary to administer these policies.
894	(1)  The agency shall work with the Department of Children
895	and Family Services to ensure access of children and families in
896	the child protection system to needed and appropriate mental
897	health and substance abuse services. This subsection expires
898	October 1, 2014.
899	(2)  The agency may enter into agreements with appropriate
900	agents of other state agencies or of any agency of the Federal
901	Government and accept such duties in respect to social welfare
902	or public aid as may be necessary to implement the provisions of
903	Title XIX of the Social Security Act and ss. 409.901-409.920.
904	This subsection expires October 1, 2016.
905	(3)  The agency may contract with health maintenance
906	organizations certified pursuant to part I of chapter 641 for
907	the provision of services to recipients. This subsection expires
908	October 1, 2014.
909	(4)  The agency may contract with:
910	(a)  An entity that provides no prepaid health care
911	services other than Medicaid services under contract with the
912	agency and which is owned and operated by a county, county
913	health department, or county-owned and operated hospital to
914	provide health care services on a prepaid or fixed-sum basis to
915	recipients, which entity may provide such prepaid services
916	either directly or through arrangements with other providers.
917	Such prepaid health care services entities must be licensed
918	under parts I and III of chapter 641. An entity recognized under
919	this paragraph which demonstrates to the satisfaction of the
920	Office of Insurance Regulation of the Financial Services
921	Commission that it is backed by the full faith and credit of the
922	county in which it is located may be exempted from s. 641.225.
923	This paragraph expires October 1, 2014.
924	(b)  An entity that is providing comprehensive behavioral
925	health care services to certain Medicaid recipients through a
926	capitated, prepaid arrangement pursuant to the federal waiver
927	provided for by s. 409.905(5). Such entity must be licensed
928	under chapter 624, chapter 636, or chapter 641, or authorized
929	under paragraph (c) or paragraph (d), and must possess the
930	clinical systems and operational competence to manage risk and
931	provide comprehensive behavioral health care to Medicaid
932	recipients. As used in this paragraph, the term "comprehensive
933	behavioral health care services" means covered mental health and
934	substance abuse treatment services that are available to
935	Medicaid recipients. The secretary of the Department of Children
936	and Family Services shall approve provisions of procurements
937	related to children in the department's care or custody before
938	enrolling such children in a prepaid behavioral health plan. Any
939	contract awarded under this paragraph must be competitively
940	procured. In developing the behavioral health care prepaid plan
941	procurement document, the agency shall ensure that the
942	procurement document requires the contractor to develop and
943	implement a plan to ensure compliance with s. 394.4574 related
944	to services provided to residents of licensed assisted living
945	facilities that hold a limited mental health license. Except as
946	provided in subparagraph 5. 8., and except in counties where the
947	Medicaid managed care pilot program is authorized pursuant to s.
948	409.91211, the agency shall seek federal approval to contract
949	with a single entity meeting these requirements to provide
950	comprehensive behavioral health care services to all Medicaid
951	recipients not enrolled in a Medicaid managed care plan
952	authorized under s. 409.91211, a provider service network
953	authorized under paragraph (d), or a Medicaid health maintenance
954	organization in an AHCA area. In an AHCA area where the Medicaid
955	managed care pilot program is authorized pursuant to s.
956	409.91211 in one or more counties, the agency may procure a
957	contract with a single entity to serve the remaining counties as
958	an AHCA area or the remaining counties may be included with an
959	adjacent AHCA area and are subject to this paragraph. Each
960	entity must offer a sufficient choice of providers in its
961	network to ensure recipient access to care and the opportunity
962	to select a provider with whom they are satisfied. The network
963	shall include all public mental health hospitals. To ensure
964	unimpaired access to behavioral health care services by Medicaid
965	recipients, all contracts issued pursuant to this paragraph must
966	require 80 percent of the capitation paid to the managed care
967	plan, including health maintenance organizations and capitated
968	provider service networks, to be expended for the provision of
969	behavioral health care services. If the managed care plan
970	expends less than 80 percent of the capitation paid for the
971	provision of behavioral health care services, the difference
972	shall be returned to the agency. The agency shall provide the
973	plan with a certification letter indicating the amount of
974	capitation paid during each calendar year for behavioral health
975	care services pursuant to this section. The agency may reimburse
976	for substance abuse treatment services on a fee-for-service
977	basis until the agency finds that adequate funds are available
978	for capitated, prepaid arrangements.
979	1.  By January 1, 2001, The agency shall modify the
980	contracts with the entities providing comprehensive inpatient
981	and outpatient mental health care services to Medicaid
982	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
983	Counties, to include substance abuse treatment services.
984	2.  By July 1, 2003, the agency and the Department of
985	Children and Family Services shall execute a written agreement
986	that requires collaboration and joint development of all policy,
987	budgets, procurement documents, contracts, and monitoring plans
988	that have an impact on the state and Medicaid community mental
989	health and targeted case management programs.
990	2.3.  Except as provided in subparagraph 5. 8., by July 1,
991	2006, the agency and the Department of Children and Family
992	Services shall contract with managed care entities in each AHCA
993	area except area 6 or arrange to provide comprehensive inpatient
994	and outpatient mental health and substance abuse services
995	through capitated prepaid arrangements to all Medicaid
996	recipients who are eligible to participate in such plans under
997	federal law and regulation. In AHCA areas where eligible
998	individuals number less than 150,000, the agency shall contract
999	with a single managed care plan to provide comprehensive
1000	behavioral health services to all recipients who are not
1001	enrolled in a Medicaid health maintenance organization, a
1002	provider service network authorized under paragraph (d), or a
1003	Medicaid capitated managed care plan authorized under s.
1004	409.91211. The agency may contract with more than one
1005	comprehensive behavioral health provider to provide care to
1006	recipients who are not enrolled in a Medicaid capitated managed
1007	care plan authorized under s. 409.91211, a provider service
1008	network authorized under paragraph (d), or a Medicaid health
1009	maintenance organization in AHCA areas where the eligible
1010	population exceeds 150,000. In an AHCA area where the Medicaid
1011	managed care pilot program is authorized pursuant to s.
1012	409.91211 in one or more counties, the agency may procure a
1013	contract with a single entity to serve the remaining counties as
1014	an AHCA area or the remaining counties may be included with an
1015	adjacent AHCA area and shall be subject to this paragraph.
1016	Contracts for comprehensive behavioral health providers awarded
1017	pursuant to this section shall be competitively procured. Both
1018	for-profit and not-for-profit corporations are eligible to
1019	compete. Managed care plans contracting with the agency under
1020	subsection (3) or paragraph (d), shall provide and receive
1021	payment for the same comprehensive behavioral health benefits as
1022	provided in AHCA rules, including handbooks incorporated by
1023	reference. In AHCA area 11, the agency shall contract with at
1024	least two comprehensive behavioral health care providers to
1025	provide behavioral health care to recipients in that area who
1026	are enrolled in, or assigned to, the MediPass program. One of
1027	the behavioral health care contracts must be with the existing
1028	provider service network pilot project, as described in
1029	paragraph (d), for the purpose of demonstrating the cost-
1030	effectiveness of the provision of quality mental health services
1031	through a public hospital-operated managed care model. Payment
1032	shall be at an agreed-upon capitated rate to ensure cost
1033	savings. Of the recipients in area 11 who are assigned to
1034	MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
1035	MediPass-enrolled recipients shall be assigned to the existing
1036	provider service network in area 11 for their behavioral care.
1037	4.  By October 1, 2003, the agency and the department shall
1038	submit a plan to the Governor, the President of the Senate, and
1039	the Speaker of the House of Representatives which provides for
1040	the full implementation of capitated prepaid behavioral health
1041	care in all areas of the state.
1042	a.  Implementation shall begin in 2003 in those AHCA areas
1043	of the state where the agency is able to establish sufficient
1044	capitation rates.
1045	b.  If the agency determines that the proposed capitation
1046	rate in any area is insufficient to provide appropriate
1047	services, the agency may adjust the capitation rate to ensure
1048	that care will be available. The agency and the department may
1049	use existing general revenue to address any additional required
1050	match but may not over-obligate existing funds on an annualized
1051	basis.
1052	c.  Subject to any limitations provided in the General
1053	Appropriations Act, the agency, in compliance with appropriate
1054	federal authorization, shall develop policies and procedures
1055	that allow for certification of local and state funds.
1056	3.5.  Children residing in a statewide inpatient
1057	psychiatric program, or in a Department of Juvenile Justice or a
1058	Department of Children and Family Services residential program
1059	approved as a Medicaid behavioral health overlay services
1060	provider may not be included in a behavioral health care prepaid
1061	health plan or any other Medicaid managed care plan pursuant to
1062	this paragraph.
1063	6.  In converting to a prepaid system of delivery, the
1064	agency shall in its procurement document require an entity
1065	providing only comprehensive behavioral health care services to
1066	prevent the displacement of indigent care patients by enrollees
1067	in the Medicaid prepaid health plan providing behavioral health
1068	care services from facilities receiving state funding to provide
1069	indigent behavioral health care, to facilities licensed under
1070	chapter 395 which do not receive state funding for indigent
1071	behavioral health care, or reimburse the unsubsidized facility
1072	for the cost of behavioral health care provided to the displaced
1073	indigent care patient.
1074	4.7.  Traditional community mental health providers under
1075	contract with the Department of Children and Family Services
1076	pursuant to part IV of chapter 394, child welfare providers
1077	under contract with the Department of Children and Family
1078	Services in areas 1 and 6, and inpatient mental health providers
1079	licensed pursuant to chapter 395 must be offered an opportunity
1080	to accept or decline a contract to participate in any provider
1081	network for prepaid behavioral health services.
1082	5.8.  All Medicaid-eligible children, except children in
1083	area 1 and children in Highlands County, Hardee County, Polk
1084	County, or Manatee County of area 6, that are open for child
1085	welfare services in the HomeSafeNet system, shall receive their
1086	behavioral health care services through a specialty prepaid plan
1087	operated by community-based lead agencies through a single
1088	agency or formal agreements among several agencies. The
1089	specialty prepaid plan must result in savings to the state
1090	comparable to savings achieved in other Medicaid managed care
1091	and prepaid programs. Such plan must provide mechanisms to
1092	maximize state and local revenues. The specialty prepaid plan
1093	shall be developed by the agency and the Department of Children
1094	and Family Services. The agency may seek federal waivers to
1095	implement this initiative. Medicaid-eligible children whose
1096	cases are open for child welfare services in the HomeSafeNet
1097	system and who reside in AHCA area 10 are exempt from the
1098	specialty prepaid plan upon the development of a service
1099	delivery mechanism for children who reside in area 10 as
1100	specified in s. 409.91211(3)(dd).
1101
1102	This paragraph expires October 1, 2014.
1103	(c)  A federally qualified health center or an entity owned
1104	by one or more federally qualified health centers or an entity
1105	owned by other migrant and community health centers receiving
1106	non-Medicaid financial support from the Federal Government to
1107	provide health care services on a prepaid or fixed-sum basis to
1108	recipients. A federally qualified health center or an entity
1109	that is owned by one or more federally qualified health centers
1110	and is reimbursed by the agency on a prepaid basis is exempt
1111	from parts I and III of chapter 641, but must comply with the
1112	solvency requirements in s. 641.2261(2) and meet the appropriate
1113	requirements governing financial reserve, quality assurance, and
1114	patients' rights established by the agency. This paragraph
1115	expires October 1, 2014.
1116	(d)1.  A provider service network may be reimbursed on a
1117	fee-for-service or prepaid basis. Prepaid provider service
1118	networks shall receive per-member, per-month payments. A
1119	provider service network that does not choose to be a prepaid
1120	plan shall receive fee-for-service rates with a shared savings
1121	settlement. The fee-for-service option shall be available to a
1122	provider service network only for the first 3 years of the
1123	plan's operation or until the contract year beginning October 1,
1124	2012, whichever is sooner. The agency shall annually conduct
1125	cost reconciliations to determine the amount of cost savings
1126	achieved by fee-for-service provider service networks for the
1127	dates of service in the period being reconciled. Only payments
1128	for covered services for dates of service within the
1129	reconciliation period and paid within 6 months after the last
1130	date of service in the reconciliation period shall be included.
1131	The agency shall perform the necessary adjustments for the
1132	inclusion of claims incurred but not reported within the
1133	reconciliation for claims that could be received and paid by the
1134	agency after the 6-month claims processing time lag. The agency
1135	shall provide the results of the reconciliations to the fee-for-
1136	service provider service networks within 45 days after the end
1137	of the reconciliation period. The fee-for-service provider
1138	service networks shall review and provide written comments or a
1139	letter of concurrence to the agency within 45 days after receipt
1140	of the reconciliation results. This reconciliation shall be
1141	considered final.
1142	2.  A provider service network which is reimbursed by the
1143	agency on a prepaid basis shall be exempt from parts I and III
1144	of chapter 641, but must comply with the solvency requirements
1145	in s. 641.2261(2) and meet appropriate financial reserve,
1146	quality assurance, and patient rights requirements as
1147	established by the agency.
1148	3.  Medicaid recipients assigned to a provider service
1149	network shall be chosen equally from those who would otherwise
1150	have been assigned to prepaid plans and MediPass. The agency is
1151	authorized to seek federal Medicaid waivers as necessary to
1152	implement the provisions of this section. This subparagraph
1153	expires October 1, 2014. Any contract previously awarded to a
1154	provider service network operated by a hospital pursuant to this
1155	subsection shall remain in effect for a period of 3 years
1156	following the current contract expiration date, regardless of
1157	any contractual provisions to the contrary.
1158	4.  A provider service network is a network established or
1159	organized and operated by a health care provider, or group of
1160	affiliated health care providers, including minority physician
1161	networks and emergency room diversion programs that meet the
1162	requirements of s. 409.91211, which provides a substantial
1163	proportion of the health care items and services under a
1164	contract directly through the provider or affiliated group of
1165	providers and may make arrangements with physicians or other
1166	health care professionals, health care institutions, or any
1167	combination of such individuals or institutions to assume all or
1168	part of the financial risk on a prospective basis for the
1169	provision of basic health services by the physicians, by other
1170	health professionals, or through the institutions. The health
1171	care providers must have a controlling interest in the governing
1172	body of the provider service network organization.
1173	(e)  An entity that provides only comprehensive behavioral
1174	health care services to certain Medicaid recipients through an
1175	administrative services organization agreement. Such an entity
1176	must possess the clinical systems and operational competence to
1177	provide comprehensive health care to Medicaid recipients. As
1178	used in this paragraph, the term "comprehensive behavioral
1179	health care services" means covered mental health and substance
1180	abuse treatment services that are available to Medicaid
1181	recipients. Any contract awarded under this paragraph must be
1182	competitively procured. The agency must ensure that Medicaid
1183	recipients have available the choice of at least two managed
1184	care plans for their behavioral health care services. This
1185	paragraph expires October 1, 2014.
1186	(f)  An entity that provides in-home physician services to
1187	test the cost-effectiveness of enhanced home-based medical care
1188	to Medicaid recipients with degenerative neurological diseases
1189	and other diseases or disabling conditions associated with high
1190	costs to Medicaid. The program shall be designed to serve very
1191	disabled persons and to reduce Medicaid reimbursed costs for
1192	inpatient, outpatient, and emergency department services. The
1193	agency shall contract with vendors on a risk-sharing basis.
1194	(g)  Children's provider networks that provide care
1195	coordination and care management for Medicaid-eligible pediatric
1196	patients, primary care, authorization of specialty care, and
1197	other urgent and emergency care through organized providers
1198	designed to service Medicaid eligibles under age 18 and
1199	pediatric emergency departments' diversion programs. The
1200	networks shall provide after-hour operations, including evening
1201	and weekend hours, to promote, when appropriate, the use of the
1202	children's networks rather than hospital emergency departments.
1203	(f)(h)  An entity authorized in s. 430.205 to contract with
1204	the agency and the Department of Elderly Affairs to provide
1205	health care and social services on a prepaid or fixed-sum basis
1206	to elderly recipients. Such prepaid health care services
1207	entities are exempt from the provisions of part I of chapter 641
1208	for the first 3 years of operation. An entity recognized under
1209	this paragraph that demonstrates to the satisfaction of the
1210	Office of Insurance Regulation that it is backed by the full
1211	faith and credit of one or more counties in which it operates
1212	may be exempted from s. 641.225. This paragraph expires October
1213	1, 2013.
1214	(g)(i)  A Children's Medical Services Network, as defined
1215	in s. 391.021. This paragraph expires October 1, 2014.
1216	(5)  The Agency for Health Care Administration, in
1217	partnership with the Department of Elderly Affairs, shall create
1218	an integrated, fixed-payment delivery program for Medicaid
1219	recipients who are 60 years of age or older or dually eligible
1220	for Medicare and Medicaid. The Agency for Health Care
1221	Administration shall implement the integrated program initially
1222	on a pilot basis in two areas of the state. The pilot areas
1223	shall be Area 7 and Area 11 of the Agency for Health Care
1224	Administration. Enrollment in the pilot areas shall be on a
1225	voluntary basis and in accordance with approved federal waivers
1226	and this section. The agency and its program contractors and
1227	providers shall not enroll any individual in the integrated
1228	program because the individual or the person legally responsible
1229	for the individual fails to choose to enroll in the integrated
1230	program. Enrollment in the integrated program shall be
1231	exclusively by affirmative choice of the eligible individual or
1232	by the person legally responsible for the individual. The
1233	integrated program must transfer all Medicaid services for
1234	eligible elderly individuals who choose to participate into an
1235	integrated-care management model designed to serve Medicaid
1236	recipients in the community. The integrated program must combine
1237	all funding for Medicaid services provided to individuals who
1238	are 60 years of age or older or dually eligible for Medicare and
1239	Medicaid into the integrated program, including funds for
1240	Medicaid home and community-based waiver services; all Medicaid
1241	services authorized in ss. 409.905 and 409.906, excluding funds
1242	for Medicaid nursing home services unless the agency is able to
1243	demonstrate how the integration of the funds will improve
1244	coordinated care for these services in a less costly manner; and
1245	Medicare coinsurance and deductibles for persons dually eligible
1246	for Medicaid and Medicare as prescribed in s. 409.908(13).
1247	(a)  Individuals who are 60 years of age or older or dually
1248	eligible for Medicare and Medicaid and enrolled in the
1249	developmental disabilities waiver program, the family and
1250	supported-living waiver program, the project AIDS care waiver
1251	program, the traumatic brain injury and spinal cord injury
1252	waiver program, the consumer-directed care waiver program, and
1253	the program of all-inclusive care for the elderly program, and
1254	residents of institutional care facilities for the
1255	developmentally disabled, must be excluded from the integrated
1256	program.
1257	(b)  Managed care entities who meet or exceed the agency's
1258	minimum standards are eligible to operate the integrated
1259	program. Entities eligible to participate include managed care
1260	organizations licensed under chapter 641, including entities
1261	eligible to participate in the nursing home diversion program,
1262	other qualified providers as defined in s. 430.703(7), community
1263	care for the elderly lead agencies, and other state-certified
1264	community service networks that meet comparable standards as
1265	defined by the agency, in consultation with the Department of
1266	Elderly Affairs and the Office of Insurance Regulation, to be
1267	financially solvent and able to take on financial risk for
1268	managed care. Community service networks that are certified
1269	pursuant to the comparable standards defined by the agency are
1270	not required to be licensed under chapter 641. Managed care
1271	entities who operate the integrated program shall be subject to
1272	s. 408.7056. Eligible entities shall choose to serve enrollees
1273	who are dually eligible for Medicare and Medicaid, enrollees who
1274	are 60 years of age or older, or both.
1275	(c)  The agency must ensure that the capitation-rate-
1276	setting methodology for the integrated program is actuarially
1277	sound and reflects the intent to provide quality care in the
1278	least restrictive setting. The agency must also require
1279	integrated-program providers to develop a credentialing system
1280	for service providers and to contract with all Gold Seal nursing
1281	homes, where feasible, and exclude, where feasible, chronically
1282	poor-performing facilities and providers as defined by the
1283	agency. The integrated program must develop and maintain an
1284	informal provider grievance system that addresses provider
1285	payment and contract problems. The agency shall also establish a
1286	formal grievance system to address those issues that were not
1287	resolved through the informal grievance system. The integrated
1288	program must provide that if the recipient resides in a
1289	noncontracted residential facility licensed under chapter 400 or
1290	chapter 429 at the time of enrollment in the integrated program,
1291	the recipient must be permitted to continue to reside in the
1292	noncontracted facility as long as the recipient desires. The
1293	integrated program must also provide that, in the absence of a
1294	contract between the integrated-program provider and the
1295	residential facility licensed under chapter 400 or chapter 429,
1296	current Medicaid rates must prevail. The integrated-program
1297	provider must ensure that electronic nursing home claims that
1298	contain sufficient information for processing are paid within 10
1299	business days after receipt. Alternately, the integrated-program
1300	provider may establish a capitated payment mechanism to
1301	prospectively pay nursing homes at the beginning of each month.
1302	The agency and the Department of Elderly Affairs must jointly
1303	develop procedures to manage the services provided through the
1304	integrated program in order to ensure quality and recipient
1305	choice.
1306	(d)  The Office of Program Policy Analysis and Government
1307	Accountability, in consultation with the Auditor General, shall
1308	comprehensively evaluate the pilot project for the integrated,
1309	fixed-payment delivery program for Medicaid recipients created
1310	under this subsection. The evaluation shall begin as soon as
1311	Medicaid recipients are enrolled in the managed care pilot
1312	program plans and shall continue for 24 months thereafter. The
1313	evaluation must include assessments of each managed care plan in
1314	the integrated program with regard to cost savings; consumer
1315	education, choice, and access to services; coordination of care;
1316	and quality of care. The evaluation must describe administrative
1317	or legal barriers to the implementation and operation of the
1318	pilot program and include recommendations regarding statewide
1319	expansion of the pilot program. The office shall submit its
1320	evaluation report to the Governor, the President of the Senate,
1321	and the Speaker of the House of Representatives no later than
1322	December 31, 2009.
1323	(e)  The agency may seek federal waivers or Medicaid state
1324	plan amendments and adopt rules as necessary to administer the
1325	integrated program. The agency may implement the approved
1326	federal waivers and other provisions as specified in this
1327	subsection.
1328	(f)  The implementation of the integrated, fixed-payment
1329	delivery program created under this subsection is subject to an
1330	appropriation in the General Appropriations Act.
1331	(5)(6)  The agency may contract with any public or private
1332	entity otherwise authorized by this section on a prepaid or
1333	fixed-sum basis for the provision of health care services to
1334	recipients. An entity may provide prepaid services to
1335	recipients, either directly or through arrangements with other
1336	entities, if each entity involved in providing services:
1337	(a)  Is organized primarily for the purpose of providing
1338	health care or other services of the type regularly offered to
1339	Medicaid recipients;
1340	(b)  Ensures that services meet the standards set by the
1341	agency for quality, appropriateness, and timeliness;
1342	(c)  Makes provisions satisfactory to the agency for
1343	insolvency protection and ensures that neither enrolled Medicaid
1344	recipients nor the agency will be liable for the debts of the
1345	entity;
1346	(d)  Submits to the agency, if a private entity, a
1347	financial plan that the agency finds to be fiscally sound and
1348	that provides for working capital in the form of cash or
1349	equivalent liquid assets excluding revenues from Medicaid
1350	premium payments equal to at least the first 3 months of
1351	operating expenses or $200,000, whichever is greater;
1352	(e)  Furnishes evidence satisfactory to the agency of
1353	adequate liability insurance coverage or an adequate plan of
1354	self-insurance to respond to claims for injuries arising out of
1355	the furnishing of health care;
1356	(f)  Provides, through contract or otherwise, for periodic
1357	review of its medical facilities and services, as required by
1358	the agency; and
1359	(g)  Provides organizational, operational, financial, and
1360	other information required by the agency.
1361
1362	This subsection expires October 1, 2014.
1363	(6)(7)  The agency may contract on a prepaid or fixed-sum
1364	basis with any health insurer that:
1365	(a)  Pays for health care services provided to enrolled
1366	Medicaid recipients in exchange for a premium payment paid by
1367	the agency;
1368	(b)  Assumes the underwriting risk; and
1369	(c)  Is organized and licensed under applicable provisions
1370	of the Florida Insurance Code and is currently in good standing
1371	with the Office of Insurance Regulation.
1372
1373	This subsection expires October 1, 2014.
1374	(7)(8)(a)  The agency may contract on a prepaid or fixed-
1375	sum basis with an exclusive provider organization to provide
1376	health care services to Medicaid recipients provided that the
1377	exclusive provider organization meets applicable managed care
1378	plan requirements in this section, ss. 409.9122, 409.9123,
1379	409.9128, and 627.6472, and other applicable provisions of law.
1380	This subsection expires October 1, 2014.
1381	(b)  For a period of no longer than 24 months after the
1382	effective date of this paragraph, when a member of an exclusive
1383	provider organization that is contracted by the agency to
1384	provide health care services to Medicaid recipients in rural
1385	areas without a health maintenance organization obtains services
1386	from a provider that participates in the Medicaid program in
1387	this state, the provider shall be paid in accordance with the
1388	appropriate fee schedule for services provided to eligible
1389	Medicaid recipients. The agency may seek waiver authority to
1390	implement this paragraph.
1391	(8)(9)  The Agency for Health Care Administration may
1392	provide cost-effective purchasing of chiropractic services on a
1393	fee-for-service basis to Medicaid recipients through
1394	arrangements with a statewide chiropractic preferred provider
1395	organization incorporated in this state as a not-for-profit
1396	corporation. The agency shall ensure that the benefit limits and
1397	prior authorization requirements in the current Medicaid program
1398	shall apply to the services provided by the chiropractic
1399	preferred provider organization. This subsection expires October
1400	1, 2014.
1401	(9)(10)  The agency shall not contract on a prepaid or
1402	fixed-sum basis for Medicaid services with an entity which knows
1403	or reasonably should know that any officer, director, agent,
1404	managing employee, or owner of stock or beneficial interest in
1405	excess of 5 percent common or preferred stock, or the entity
1406	itself, has been found guilty of, regardless of adjudication, or
1407	entered a plea of nolo contendere, or guilty, to:
1408	(a)  Fraud;
1409	(b)  Violation of federal or state antitrust statutes,
1410	including those proscribing price fixing between competitors and
1411	the allocation of customers among competitors;
1412	(c)  Commission of a felony involving embezzlement, theft,
1413	forgery, income tax evasion, bribery, falsification or
1414	destruction of records, making false statements, receiving
1415	stolen property, making false claims, or obstruction of justice;
1416	or
1417	(d)  Any crime in any jurisdiction which directly relates
1418	to the provision of health services on a prepaid or fixed-sum
1419	basis.
1420
1421	This subsection expires October 1, 2014.
1422	(10)(11)  The agency, after notifying the Legislature, may
1423	apply for waivers of applicable federal laws and regulations as
1424	necessary to implement more appropriate systems of health care
1425	for Medicaid recipients and reduce the cost of the Medicaid
1426	program to the state and federal governments and shall implement
1427	such programs, after legislative approval, within a reasonable
1428	period of time after federal approval. These programs must be
1429	designed primarily to reduce the need for inpatient care,
1430	custodial care and other long-term or institutional care, and
1431	other high-cost services. Prior to seeking legislative approval
1432	of such a waiver as authorized by this subsection, the agency
1433	shall provide notice and an opportunity for public comment.
1434	Notice shall be provided to all persons who have made requests
1435	of the agency for advance notice and shall be published in the
1436	Florida Administrative Weekly not less than 28 days prior to the
1437	intended action. This subsection expires October 1, 2016.
1438	(11)(12)  The agency shall establish a postpayment
1439	utilization control program designed to identify recipients who
1440	may inappropriately overuse or underuse Medicaid services and
1441	shall provide methods to correct such misuse. This subsection
1442	expires October 1, 2014.
1443	(12)(13)  The agency shall develop and provide coordinated
1444	systems of care for Medicaid recipients and may contract with
1445	public or private entities to develop and administer such
1446	systems of care among public and private health care providers
1447	in a given geographic area. This subsection expires October 1,
1448	2014.
1449	(13)(14)(a)  The agency shall operate or contract for the
1450	operation of utilization management and incentive systems
1451	designed to encourage cost-effective use of services and to
1452	eliminate services that are medically unnecessary. The agency
1453	shall track Medicaid provider prescription and billing patterns
1454	and evaluate them against Medicaid medical necessity criteria
1455	and coverage and limitation guidelines adopted by rule. Medical
1456	necessity determination requires that service be consistent with
1457	symptoms or confirmed diagnosis of illness or injury under
1458	treatment and not in excess of the patient's needs. The agency
1459	shall conduct reviews of provider exceptions to peer group norms
1460	and shall, using statistical methodologies, provider profiling,
1461	and analysis of billing patterns, detect and investigate
1462	abnormal or unusual increases in billing or payment of claims
1463	for Medicaid services and medically unnecessary provision of
1464	services. Providers that demonstrate a pattern of submitting
1465	claims for medically unnecessary services shall be referred to
1466	the Medicaid program integrity unit for investigation. In its
1467	annual report, required in s. 409.913, the agency shall report
1468	on its efforts to control overutilization as described in this
1469	subsection paragraph. This subsection expires October 1, 2014.
1470	(b)  The agency shall develop a procedure for determining
1471	whether health care providers and service vendors can provide
1472	the Medicaid program using a business case that demonstrates
1473	whether a particular good or service can offset the cost of
1474	providing the good or service in an alternative setting or
1475	through other means and therefore should receive a higher
1476	reimbursement. The business case must include, but need not be
1477	limited to:
1478	1.  A detailed description of the good or service to be
1479	provided, a description and analysis of the agency's current
1480	performance of the service, and a rationale documenting how
1481	providing the service in an alternative setting would be in the
1482	best interest of the state, the agency, and its clients.
1483	2.  A cost-benefit analysis documenting the estimated
1484	specific direct and indirect costs, savings, performance
1485	improvements, risks, and qualitative and quantitative benefits
1486	involved in or resulting from providing the service. The cost-
1487	benefit analysis must include a detailed plan and timeline
1488	identifying all actions that must be implemented to realize
1489	expected benefits. The Secretary of Health Care Administration
1490	shall verify that all costs, savings, and benefits are valid and
1491	achievable.
1492	(c)  If the agency determines that the increased
1493	reimbursement is cost-effective, the agency shall recommend a
1494	change in the reimbursement schedule for that particular good or
1495	service. If, within 12 months after implementing any rate change
1496	under this procedure, the agency determines that costs were not
1497	offset by the increased reimbursement schedule, the agency may
1498	revert to the former reimbursement schedule for the particular
1499	good or service.
1500	(14)(15)(a)  The agency shall operate the Comprehensive
1501	Assessment and Review for Long-Term Care Services (CARES)
1502	nursing facility preadmission screening program to ensure that
1503	Medicaid payment for nursing facility care is made only for
1504	individuals whose conditions require such care and to ensure
1505	that long-term care services are provided in the setting most
1506	appropriate to the needs of the person and in the most
1507	economical manner possible. The CARES program shall also ensure
1508	that individuals participating in Medicaid home and community-
1509	based waiver programs meet criteria for those programs,
1510	consistent with approved federal waivers.
1511	(b)  The agency shall operate the CARES program through an
1512	interagency agreement with the Department of Elderly Affairs.
1513	The agency, in consultation with the Department of Elderly
1514	Affairs, may contract for any function or activity of the CARES
1515	program, including any function or activity required by 42
1516	C.F.R. part 483.20, relating to preadmission screening and
1517	resident review.
1518	(c)  Prior to making payment for nursing facility services
1519	for a Medicaid recipient, the agency must verify that the
1520	nursing facility preadmission screening program has determined
1521	that the individual requires nursing facility care and that the
1522	individual cannot be safely served in community-based programs.
1523	The nursing facility preadmission screening program shall refer
1524	a Medicaid recipient to a community-based program if the
1525	individual could be safely served at a lower cost and the
1526	recipient chooses to participate in such program. For
1527	individuals whose nursing home stay is initially funded by
1528	Medicare and Medicare coverage is being terminated for lack of
1529	progress towards rehabilitation, CARES staff shall consult with
1530	the person making the determination of progress toward
1531	rehabilitation to ensure that the recipient is not being
1532	inappropriately disqualified from Medicare coverage. If, in
1533	their professional judgment, CARES staff believes that a
1534	Medicare beneficiary is still making progress toward
1535	rehabilitation, they may assist the Medicare beneficiary with an
1536	appeal of the disqualification from Medicare coverage. The use
1537	of CARES teams to review Medicare denials for coverage under
1538	this section is authorized only if it is determined that such
1539	reviews qualify for federal matching funds through Medicaid. The
1540	agency shall seek or amend federal waivers as necessary to
1541	implement this section.
1542	(d)  For the purpose of initiating immediate prescreening
1543	and diversion assistance for individuals residing in nursing
1544	homes and in order to make families aware of alternative long-
1545	term care resources so that they may choose a more cost-
1546	effective setting for long-term placement, CARES staff shall
1547	conduct an assessment and review of a sample of individuals
1548	whose nursing home stay is expected to exceed 20 days,
1549	regardless of the initial funding source for the nursing home
1550	placement. CARES staff shall provide counseling and referral
1551	services to these individuals regarding choosing appropriate
1552	long-term care alternatives. This paragraph does not apply to
1553	continuing care facilities licensed under chapter 651 or to
1554	retirement communities that provide a combination of nursing
1555	home, independent living, and other long-term care services.
1556	(e)  By January 15 of each year, the agency shall submit a
1557	report to the Legislature describing the operations of the CARES
1558	program. The report must describe:
1559	1.  Rate of diversion to community alternative programs;
1560	2.  CARES program staffing needs to achieve additional
1561	diversions;
1562	3.  Reasons the program is unable to place individuals in
1563	less restrictive settings when such individuals desired such
1564	services and could have been served in such settings;
1565	4.  Barriers to appropriate placement, including barriers
1566	due to policies or operations of other agencies or state-funded
1567	programs; and
1568	5.  Statutory changes necessary to ensure that individuals
1569	in need of long-term care services receive care in the least
1570	restrictive environment.
1571	(f)  The Department of Elderly Affairs shall track
1572	individuals over time who are assessed under the CARES program
1573	and who are diverted from nursing home placement. By January 15
1574	of each year, the department shall submit to the Legislature a
1575	longitudinal study of the individuals who are diverted from
1576	nursing home placement. The study must include:
1577	1.  The demographic characteristics of the individuals
1578	assessed and diverted from nursing home placement, including,
1579	but not limited to, age, race, gender, frailty, caregiver
1580	status, living arrangements, and geographic location;
1581	2.  A summary of community services provided to individuals
1582	for 1 year after assessment and diversion;
1583	3.  A summary of inpatient hospital admissions for
1584	individuals who have been diverted; and
1585	4.  A summary of the length of time between diversion and
1586	subsequent entry into a nursing home or death.
1587
1588	This subsection expires October 1, 2013.
1589	(15)(16)(a)  The agency shall identify health care
1590	utilization and price patterns within the Medicaid program which
1591	are not cost-effective or medically appropriate and assess the
1592	effectiveness of new or alternate methods of providing and
1593	monitoring service, and may implement such methods as it
1594	considers appropriate. Such methods may include disease
1595	management initiatives, an integrated and systematic approach
1596	for managing the health care needs of recipients who are at risk
1597	of or diagnosed with a specific disease by using best practices,
1598	prevention strategies, clinical-practice improvement, clinical
1599	interventions and protocols, outcomes research, information
1600	technology, and other tools and resources to reduce overall
1601	costs and improve measurable outcomes.
1602	(b)  The responsibility of the agency under this subsection
1603	shall include the development of capabilities to identify actual
1604	and optimal practice patterns; patient and provider educational
1605	initiatives; methods for determining patient compliance with
1606	prescribed treatments; fraud, waste, and abuse prevention and
1607	detection programs; and beneficiary case management programs.
1608	1.  The practice pattern identification program shall
1609	evaluate practitioner prescribing patterns based on national and
1610	regional practice guidelines, comparing practitioners to their
1611	peer groups. The agency and its Drug Utilization Review Board
1612	shall consult with the Department of Health and a panel of
1613	practicing health care professionals consisting of the
1614	following: the Speaker of the House of Representatives and the
1615	President of the Senate shall each appoint three physicians
1616	licensed under chapter 458 or chapter 459; and the Governor
1617	shall appoint two pharmacists licensed under chapter 465 and one
1618	dentist licensed under chapter 466 who is an oral surgeon. Terms
1619	of the panel members shall expire at the discretion of the
1620	appointing official. The advisory panel shall be responsible for
1621	evaluating treatment guidelines and recommending ways to
1622	incorporate their use in the practice pattern identification
1623	program. Practitioners who are prescribing inappropriately or
1624	inefficiently, as determined by the agency, may have their
1625	prescribing of certain drugs subject to prior authorization or
1626	may be terminated from all participation in the Medicaid
1627	program.
1628	2.  The agency shall also develop educational interventions
1629	designed to promote the proper use of medications by providers
1630	and beneficiaries.
1631	3.  The agency shall implement a pharmacy fraud, waste, and
1632	abuse initiative that may include a surety bond or letter of
1633	credit requirement for participating pharmacies, enhanced
1634	provider auditing practices, the use of additional fraud and
1635	abuse software, recipient management programs for beneficiaries
1636	inappropriately using their benefits, and other steps that will
1637	eliminate provider and recipient fraud, waste, and abuse. The
1638	initiative shall address enforcement efforts to reduce the
1639	number and use of counterfeit prescriptions.
1640	4.  By September 30, 2002, the agency shall contract with
1641	an entity in the state to implement a wireless handheld clinical
1642	pharmacology drug information database for practitioners. The
1643	initiative shall be designed to enhance the agency's efforts to
1644	reduce fraud, abuse, and errors in the prescription drug benefit
1645	program and to otherwise further the intent of this paragraph.
1646	5.  By April 1, 2006, the agency shall contract with an
1647	entity to design a database of clinical utilization information
1648	or electronic medical records for Medicaid providers. This
1649	system must be web-based and allow providers to review on a
1650	real-time basis the utilization of Medicaid services, including,
1651	but not limited to, physician office visits, inpatient and
1652	outpatient hospitalizations, laboratory and pathology services,
1653	radiological and other imaging services, dental care, and
1654	patterns of dispensing prescription drugs in order to coordinate
1655	care and identify potential fraud and abuse.
1656	6.  The agency may apply for any federal waivers needed to
1657	administer this paragraph.
1658
1659	This subsection expires October 1, 2014.
1660	(16)(17)  An entity contracting on a prepaid or fixed-sum
1661	basis shall meet the surplus requirements of s. 641.225. If an
1662	entity's surplus falls below an amount equal to the surplus
1663	requirements of s. 641.225, the agency shall prohibit the entity
1664	from engaging in marketing and preenrollment activities, shall
1665	cease to process new enrollments, and may not renew the entity's
1666	contract until the required balance is achieved. The
1667	requirements of this subsection do not apply:
1668	(a)  Where a public entity agrees to fund any deficit
1669	incurred by the contracting entity; or
1670	(b)  Where the entity's performance and obligations are
1671	guaranteed in writing by a guaranteeing organization which:
1672	1.  Has been in operation for at least 5 years and has
1673	assets in excess of $50 million; or
1674	2.  Submits a written guarantee acceptable to the agency
1675	which is irrevocable during the term of the contracting entity's
1676	contract with the agency and, upon termination of the contract,
1677	until the agency receives proof of satisfaction of all
1678	outstanding obligations incurred under the contract.
1679
1680	This subsection expires October 1, 2014.
1681	(17)(18)(a)  The agency may require an entity contracting
1682	on a prepaid or fixed-sum basis to establish a restricted
1683	insolvency protection account with a federally guaranteed
1684	financial institution licensed to do business in this state. The
1685	entity shall deposit into that account 5 percent of the
1686	capitation payments made by the agency each month until a
1687	maximum total of 2 percent of the total current contract amount
1688	is reached. The restricted insolvency protection account may be
1689	drawn upon with the authorized signatures of two persons
1690	designated by the entity and two representatives of the agency.
1691	If the agency finds that the entity is insolvent, the agency may
1692	draw upon the account solely with the two authorized signatures
1693	of representatives of the agency, and the funds may be disbursed
1694	to meet financial obligations incurred by the entity under the
1695	prepaid contract. If the contract is terminated, expired, or not
1696	continued, the account balance must be released by the agency to
1697	the entity upon receipt of proof of satisfaction of all
1698	outstanding obligations incurred under this contract.
1699	(b)  The agency may waive the insolvency protection account
1700	requirement in writing when evidence is on file with the agency
1701	of adequate insolvency insurance and reinsurance that will
1702	protect enrollees if the entity becomes unable to meet its
1703	obligations.
1704
1705	(18)(19)  An entity that contracts with the agency on a
1706	prepaid or fixed-sum basis for the provision of Medicaid
1707	services shall reimburse any hospital or physician that is
1708	outside the entity's authorized geographic service area as
1709	specified in its contract with the agency, and that provides
1710	services authorized by the entity to its members, at a rate
1711	negotiated with the hospital or physician for the provision of
1712	services or according to the lesser of the following:
1713	(a)  The usual and customary charges made to the general
1714	public by the hospital or physician; or
1715	(b)  The Florida Medicaid reimbursement rate established
1716	for the hospital or physician.
1717
1718	This subsection expires October 1, 2014.
1719	(19)(20)  When a merger or acquisition of a Medicaid
1720	prepaid contractor has been approved by the Office of Insurance
1721	Regulation pursuant to s. 628.4615, the agency shall approve the
1722	assignment or transfer of the appropriate Medicaid prepaid
1723	contract upon request of the surviving entity of the merger or
1724	acquisition if the contractor and the other entity have been in
1725	good standing with the agency for the most recent 12-month
1726	period, unless the agency determines that the assignment or
1727	transfer would be detrimental to the Medicaid recipients or the
1728	Medicaid program. To be in good standing, an entity must not
1729	have failed accreditation or committed any material violation of
1730	the requirements of s. 641.52 and must meet the Medicaid
1731	contract requirements. For purposes of this section, a merger or
1732	acquisition means a change in controlling interest of an entity,
1733	including an asset or stock purchase. This subsection expires
1734	October 1, 2014.
1735	(20)(21)  Any entity contracting with the agency pursuant
1736	to this section to provide health care services to Medicaid
1737	recipients is prohibited from engaging in any of the following
1738	practices or activities:
1739	(a)  Practices that are discriminatory, including, but not
1740	limited to, attempts to discourage participation on the basis of
1741	actual or perceived health status.
1742	(b)  Activities that could mislead or confuse recipients,
1743	or misrepresent the organization, its marketing representatives,
1744	or the agency. Violations of this paragraph include, but are not
1745	limited to:
1746	1.  False or misleading claims that marketing
1747	representatives are employees or representatives of the state or
1748	county, or of anyone other than the entity or the organization
1749	by whom they are reimbursed.
1750	2.  False or misleading claims that the entity is
1751	recommended or endorsed by any state or county agency, or by any
1752	other organization which has not certified its endorsement in
1753	writing to the entity.
1754	3.  False or misleading claims that the state or county
1755	recommends that a Medicaid recipient enroll with an entity.
1756	4.  Claims that a Medicaid recipient will lose benefits
1757	under the Medicaid program, or any other health or welfare
1758	benefits to which the recipient is legally entitled, if the
1759	recipient does not enroll with the entity.
1760	(c)  Granting or offering of any monetary or other valuable
1761	consideration for enrollment, except as authorized by subsection
1762	(23) (24).
1763	(d)  Door-to-door solicitation of recipients who have not
1764	contacted the entity or who have not invited the entity to make
1765	a presentation.
1766	(e)  Solicitation of Medicaid recipients by marketing
1767	representatives stationed in state offices unless approved and
1768	supervised by the agency or its agent and approved by the
1769	affected state agency when solicitation occurs in an office of
1770	the state agency. The agency shall ensure that marketing
1771	representatives stationed in state offices shall market their
1772	managed care plans to Medicaid recipients only in designated
1773	areas and in such a way as to not interfere with the recipients'
1774	activities in the state office.
1775	(f)  Enrollment of Medicaid recipients.
1776
1777	(21)(22)  The agency may impose a fine for a violation of
1778	this section or the contract with the agency by a person or
1779	entity that is under contract with the agency. With respect to
1780	any nonwillful violation, such fine shall not exceed $2,500 per
1781	violation. In no event shall such fine exceed an aggregate
1782	amount of $10,000 for all nonwillful violations arising out of
1783	the same action. With respect to any knowing and willful
1784	violation of this section or the contract with the agency, the
1785	agency may impose a fine upon the entity in an amount not to
1786	exceed $20,000 for each such violation. In no event shall such
1787	fine exceed an aggregate amount of $100,000 for all knowing and
1788	willful violations arising out of the same action. This
1789	subsection expires October 1, 2014.
1790	(22)(23)  A health maintenance organization or a person or
1791	entity exempt from chapter 641 that is under contract with the
1792	agency for the provision of health care services to Medicaid
1793	recipients may not use or distribute marketing materials used to
1794	solicit Medicaid recipients, unless such materials have been
1795	approved by the agency. The provisions of this subsection do not
1796	apply to general advertising and marketing materials used by a
1797	health maintenance organization to solicit both non-Medicaid
1798	subscribers and Medicaid recipients. This subsection expires
1799	October 1, 2014.
1800	(23)(24)  Upon approval by the agency, health maintenance
1801	organizations and persons or entities exempt from chapter 641
1802	that are under contract with the agency for the provision of
1803	health care services to Medicaid recipients may be permitted
1804	within the capitation rate to provide additional health benefits
1805	that the agency has found are of high quality, are practicably
1806	available, provide reasonable value to the recipient, and are
1807	provided at no additional cost to the state. This subsection
1808	expires October 1, 2014.
1809	(24)(25)  The agency shall utilize the statewide health
1810	maintenance organization complaint hotline for the purpose of
1811	investigating and resolving Medicaid and prepaid health plan
1812	complaints, maintaining a record of complaints and confirmed
1813	problems, and receiving disenrollment requests made by
1814	recipients. This subsection expires October 1, 2014.
1815	(25)(26)  The agency shall require the publication of the
1816	health maintenance organization's and the prepaid health plan's
1817	consumer services telephone numbers and the "800" telephone
1818	number of the statewide health maintenance organization
1819	complaint hotline on each Medicaid identification card issued by
1820	a health maintenance organization or prepaid health plan
1821	contracting with the agency to serve Medicaid recipients and on
1822	each subscriber handbook issued to a Medicaid recipient. This
1823	subsection expires October 1, 2014.
1824	(26)(27)  The agency shall establish a health care quality
1825	improvement system for those entities contracting with the
1826	agency pursuant to this section, incorporating all the standards
1827	and guidelines developed by the Medicaid Bureau of the Health
1828	Care Financing Administration as a part of the quality assurance
1829	reform initiative. The system shall include, but need not be
1830	limited to, the following:
1831	(a)  Guidelines for internal quality assurance programs,
1832	including standards for:
1833	1.  Written quality assurance program descriptions.
1834	2.  Responsibilities of the governing body for monitoring,
1835	evaluating, and making improvements to care.
1836	3.  An active quality assurance committee.
1837	4.  Quality assurance program supervision.
1838	5.  Requiring the program to have adequate resources to
1839	effectively carry out its specified activities.
1840	6.  Provider participation in the quality assurance
1841	program.
1842	7.  Delegation of quality assurance program activities.
1843	8.  Credentialing and recredentialing.
1844	9.  Enrollee rights and responsibilities.
1845	10.  Availability and accessibility to services and care.
1846	11.  Ambulatory care facilities.
1847	12.  Accessibility and availability of medical records, as
1848	well as proper recordkeeping and process for record review.
1849	13.  Utilization review.
1850	14.  A continuity of care system.
1851	15.  Quality assurance program documentation.
1852	16.  Coordination of quality assurance activity with other
1853	management activity.
1854	17.  Delivering care to pregnant women and infants; to
1855	elderly and disabled recipients, especially those who are at
1856	risk of institutional placement; to persons with developmental
1857	disabilities; and to adults who have chronic, high-cost medical
1858	conditions.
1859	(b)  Guidelines which require the entities to conduct
1860	quality-of-care studies which:
1861	1.  Target specific conditions and specific health service
1862	delivery issues for focused monitoring and evaluation.
1863	2.  Use clinical care standards or practice guidelines to
1864	objectively evaluate the care the entity delivers or fails to
1865	deliver for the targeted clinical conditions and health services
1866	delivery issues.
1867	3.  Use quality indicators derived from the clinical care
1868	standards or practice guidelines to screen and monitor care and
1869	services delivered.
1870	(c)  Guidelines for external quality review of each
1871	contractor which require: focused studies of patterns of care;
1872	individual care review in specific situations; and followup
1873	activities on previous pattern-of-care study findings and
1874	individual-care-review findings. In designing the external
1875	quality review function and determining how it is to operate as
1876	part of the state's overall quality improvement system, the
1877	agency shall construct its external quality review organization
1878	and entity contracts to address each of the following:
1879	1.  Delineating the role of the external quality review
1880	organization.
1881	2.  Length of the external quality review organization
1882	contract with the state.
1883	3.  Participation of the contracting entities in designing
1884	external quality review organization review activities.
1885	4.  Potential variation in the type of clinical conditions
1886	and health services delivery issues to be studied at each plan.
1887	5.  Determining the number of focused pattern-of-care
1888	studies to be conducted for each plan.
1889	6.  Methods for implementing focused studies.
1890	7.  Individual care review.
1891	8.  Followup activities.
1892
1893	This subsection expires October 1, 2016.
1894	(27)(28)  In order to ensure that children receive health
1895	care services for which an entity has already been compensated,
1896	an entity contracting with the agency pursuant to this section
1897	shall achieve an annual Early and Periodic Screening, Diagnosis,
1898	and Treatment (EPSDT) Service screening rate of at least 60
1899	percent for those recipients continuously enrolled for at least
1900	8 months. The agency shall develop a method by which the EPSDT
1901	screening rate shall be calculated. For any entity which does
1902	not achieve the annual 60 percent rate, the entity must submit a
1903	corrective action plan for the agency's approval. If the entity
1904	does not meet the standard established in the corrective action
1905	plan during the specified timeframe, the agency is authorized to
1906	impose appropriate contract sanctions. At least annually, the
1907	agency shall publicly release the EPSDT Services screening rates
1908	of each entity it has contracted with on a prepaid basis to
1909	serve Medicaid recipients. This subsection expires October 1,
1910	2014.
1911	(28)(29)  The agency shall perform enrollments and
1912	disenrollments for Medicaid recipients who are eligible for
1913	MediPass or managed care plans. Notwithstanding the prohibition
1914	contained in paragraph (20)(21)(f), managed care plans may
1915	perform preenrollments of Medicaid recipients under the
1916	supervision of the agency or its agents. For the purposes of
1917	this section, the term "preenrollment" means the provision of
1918	marketing and educational materials to a Medicaid recipient and
1919	assistance in completing the application forms, but does not
1920	include actual enrollment into a managed care plan. An
1921	application for enrollment may not be deemed complete until the
1922	agency or its agent verifies that the recipient made an
1923	informed, voluntary choice. The agency, in cooperation with the
1924	Department of Children and Family Services, may test new
1925	marketing initiatives to inform Medicaid recipients about their
1926	managed care options at selected sites. The agency may contract
1927	with a third party to perform managed care plan and MediPass
1928	enrollment and disenrollment services for Medicaid recipients
1929	and may adopt rules to administer such services. The agency may
1930	adjust the capitation rate only to cover the costs of a third-
1931	party enrollment and disenrollment contract, and for agency
1932	supervision and management of the managed care plan enrollment
1933	and disenrollment contract. This subsection expires October 1,
1934	2014.
1935	(29)(30)  Any lists of providers made available to Medicaid
1936	recipients, MediPass enrollees, or managed care plan enrollees
1937	shall be arranged alphabetically showing the provider's name and
1938	specialty and, separately, by specialty in alphabetical order.
1939	This subsection expires October 1, 2014.
1940	(30)(31)  The agency shall establish an enhanced managed
1941	care quality assurance oversight function, to include at least
1942	the following components:
1943	(a)  At least quarterly analysis and followup, including
1944	sanctions as appropriate, of managed care participant
1945	utilization of services.
1946	(b)  At least quarterly analysis and followup, including
1947	sanctions as appropriate, of quality findings of the Medicaid
1948	peer review organization and other external quality assurance
1949	programs.
1950	(c)  At least quarterly analysis and followup, including
1951	sanctions as appropriate, of the fiscal viability of managed
1952	care plans.
1953	(d)  At least quarterly analysis and followup, including
1954	sanctions as appropriate, of managed care participant
1955	satisfaction and disenrollment surveys.
1956	(e)  The agency shall conduct regular and ongoing Medicaid
1957	recipient satisfaction surveys.
1958
1959	The analyses and followup activities conducted by the agency
1960	under its enhanced managed care quality assurance oversight
1961	function shall not duplicate the activities of accreditation
1962	reviewers for entities regulated under part III of chapter 641,
1963	but may include a review of the finding of such reviewers. This
1964	subsection expires October 1, 2014.
1965	(31)(32)  Each managed care plan that is under contract
1966	with the agency to provide health care services to Medicaid
1967	recipients shall annually conduct a background check with the
1968	Department of Law Enforcement of all persons with ownership
1969	interest of 5 percent or more or executive management
1970	responsibility for the managed care plan and shall submit to the
1971	agency information concerning any such person who has been found
1972	guilty of, regardless of adjudication, or has entered a plea of
1973	nolo contendere or guilty to, any of the offenses listed in s.
1974	435.04. This subsection expires October 1, 2014.
1975	(32)(33)  The agency shall, by rule, develop a process
1976	whereby a Medicaid managed care plan enrollee who wishes to
1977	enter hospice care may be disenrolled from the managed care plan
1978	within 24 hours after contacting the agency regarding such
1979	request. The agency rule shall include a methodology for the
1980	agency to recoup managed care plan payments on a pro rata basis
1981	if payment has been made for the enrollment month when
1982	disenrollment occurs. This subsection expires October 1, 2014.
1983	(33)(34)  The agency and entities that contract with the
1984	agency to provide health care services to Medicaid recipients
1985	under this section or ss. 409.91211 and 409.9122 must comply
1986	with the provisions of s. 641.513 in providing emergency
1987	services and care to Medicaid recipients and MediPass
1988	recipients. Where feasible, safe, and cost-effective, the agency
1989	shall encourage hospitals, emergency medical services providers,
1990	and other public and private health care providers to work
1991	together in their local communities to enter into agreements or
1992	arrangements to ensure access to alternatives to emergency
1993	services and care for those Medicaid recipients who need
1994	nonemergent care. The agency shall coordinate with hospitals,
1995	emergency medical services providers, private health plans,
1996	capitated managed care networks as established in s. 409.91211,
1997	and other public and private health care providers to implement
1998	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1999	and 641.31097 to develop and implement emergency department
2000	diversion programs for Medicaid recipients. This subsection
2001	expires October 1, 2014.
2002	(34)(35)  All entities providing health care services to
2003	Medicaid recipients shall make available, and encourage all
2004	pregnant women and mothers with infants to receive, and provide
2005	documentation in the medical records to reflect, the following:
2006	(a)  Healthy Start prenatal or infant screening.
2007	(b)  Healthy Start care coordination, when screening or
2008	other factors indicate need.
2009	(c)  Healthy Start enhanced services in accordance with the
2010	prenatal or infant screening results.
2011	(d)  Immunizations in accordance with recommendations of
2012	the Advisory Committee on Immunization Practices of the United
2013	States Public Health Service and the American Academy of
2014	Pediatrics, as appropriate.
2015	(e)  Counseling and services for family planning to all
2016	women and their partners.
2017	(f)  A scheduled postpartum visit for the purpose of
2018	voluntary family planning, to include discussion of all methods
2019	of contraception, as appropriate.
2020	(g)  Referral to the Special Supplemental Nutrition Program
2021	for Women, Infants, and Children (WIC).
2022
2023	This subsection expires October 1, 2014.
2024	(35)(36)  Any entity that provides Medicaid prepaid health
2025	plan services shall ensure the appropriate coordination of
2026	health care services with an assisted living facility in cases
2027	where a Medicaid recipient is both a member of the entity's
2028	prepaid health plan and a resident of the assisted living
2029	facility. If the entity is at risk for Medicaid targeted case
2030	management and behavioral health services, the entity shall
2031	inform the assisted living facility of the procedures to follow
2032	should an emergent condition arise. This subsection expires
2033	October 1, 2014.
2034	(37)  The agency may seek and implement federal waivers
2035	necessary to provide for cost-effective purchasing of home
2036	health services, private duty nursing services, transportation,
2037	independent laboratory services, and durable medical equipment
2038	and supplies through competitive bidding pursuant to s. 287.057.
2039	The agency may request appropriate waivers from the federal
2040	Health Care Financing Administration in order to competitively
2041	bid such services. The agency may exclude providers not selected
2042	through the bidding process from the Medicaid provider network.
2043	(36)(38)  The agency shall enter into agreements with not-
2044	for-profit organizations based in this state for the purpose of
2045	providing vision screening. This subsection expires October 1,
2046	2014.
2047	(37)(39)(a)  The agency shall implement a Medicaid
2048	prescribed-drug spending-control program that includes the
2049	following components:
2050	1.  A Medicaid preferred drug list, which shall be a
2051	listing of cost-effective therapeutic options recommended by the
2052	Medicaid Pharmacy and Therapeutics Committee established
2053	pursuant to s. 409.91195 and adopted by the agency for each
2054	therapeutic class on the preferred drug list. At the discretion
2055	of the committee, and when feasible, the preferred drug list
2056	should include at least two products in a therapeutic class. The
2057	agency may post the preferred drug list and updates to the
2058	preferred drug list on an Internet website without following the
2059	rulemaking procedures of chapter 120. Antiretroviral agents are
2060	excluded from the preferred drug list. The agency shall also
2061	limit the amount of a prescribed drug dispensed to no more than
2062	a 34-day supply unless the drug products' smallest marketed
2063	package is greater than a 34-day supply, or the drug is
2064	determined by the agency to be a maintenance drug in which case
2065	a 100-day maximum supply may be authorized. The agency is
2066	authorized to seek any federal waivers necessary to implement
2067	these cost-control programs and to continue participation in the
2068	federal Medicaid rebate program, or alternatively to negotiate
2069	state-only manufacturer rebates. The agency may adopt rules to
2070	implement this subparagraph. The agency shall continue to
2071	provide unlimited contraceptive drugs and items. The agency must
2072	establish procedures to ensure that:
2073	a.  There is a response to a request for prior consultation
2074	by telephone or other telecommunication device within 24 hours
2075	after receipt of a request for prior consultation; and
2076	b.  A 72-hour supply of the drug prescribed is provided in
2077	an emergency or when the agency does not provide a response
2078	within 24 hours as required by sub-subparagraph a.
2079	2.  Reimbursement to pharmacies for Medicaid prescribed
2080	drugs shall be set at the lesser of: the average wholesale price
2081	(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2082	plus 4.75 percent, the federal upper limit (FUL), the state
2083	maximum allowable cost (SMAC), or the usual and customary (UAC)
2084	charge billed by the provider.
2085	3.  The agency shall develop and implement a process for
2086	managing the drug therapies of Medicaid recipients who are using
2087	significant numbers of prescribed drugs each month. The
2088	management process may include, but is not limited to,
2089	comprehensive, physician-directed medical-record reviews, claims
2090	analyses, and case evaluations to determine the medical
2091	necessity and appropriateness of a patient's treatment plan and
2092	drug therapies. The agency may contract with a private
2093	organization to provide drug-program-management services. The
2094	Medicaid drug benefit management program shall include
2095	initiatives to manage drug therapies for HIV/AIDS patients,
2096	patients using 20 or more unique prescriptions in a 180-day
2097	period, and the top 1,000 patients in annual spending. The
2098	agency shall enroll any Medicaid recipient in the drug benefit
2099	management program if he or she meets the specifications of this
2100	provision and is not enrolled in a Medicaid health maintenance
2101	organization.
2102	4.  The agency may limit the size of its pharmacy network
2103	based on need, competitive bidding, price negotiations,
2104	credentialing, or similar criteria. The agency shall give
2105	special consideration to rural areas in determining the size and
2106	location of pharmacies included in the Medicaid pharmacy
2107	network. A pharmacy credentialing process may include criteria
2108	such as a pharmacy's full-service status, location, size,
2109	patient educational programs, patient consultation, disease
2110	management services, and other characteristics. The agency may
2111	impose a moratorium on Medicaid pharmacy enrollment when it is
2112	determined that it has a sufficient number of Medicaid-
2113	participating providers. The agency must allow dispensing
2114	practitioners to participate as a part of the Medicaid pharmacy
2115	network regardless of the practitioner's proximity to any other
2116	entity that is dispensing prescription drugs under the Medicaid
2117	program. A dispensing practitioner must meet all credentialing
2118	requirements applicable to his or her practice, as determined by
2119	the agency.
2120	5.  The agency shall develop and implement a program that
2121	requires Medicaid practitioners who prescribe drugs to use a
2122	counterfeit-proof prescription pad for Medicaid prescriptions.
2123	The agency shall require the use of standardized counterfeit-
2124	proof prescription pads by Medicaid-participating prescribers or
2125	prescribers who write prescriptions for Medicaid recipients. The
2126	agency may implement the program in targeted geographic areas or
2127	statewide.
2128	6.  The agency may enter into arrangements that require
2129	manufacturers of generic drugs prescribed to Medicaid recipients
2130	to provide rebates of at least 15.1 percent of the average
2131	manufacturer price for the manufacturer's generic products.
2132	These arrangements shall require that if a generic-drug
2133	manufacturer pays federal rebates for Medicaid-reimbursed drugs
2134	at a level below 15.1 percent, the manufacturer must provide a
2135	supplemental rebate to the state in an amount necessary to
2136	achieve a 15.1-percent rebate level.
2137	7.  The agency may establish a preferred drug list as
2138	described in this subsection, and, pursuant to the establishment
2139	of such preferred drug list, it is authorized to negotiate
2140	supplemental rebates from manufacturers that are in addition to
2141	those required by Title XIX of the Social Security Act and at no
2142	less than 14 percent of the average manufacturer price as
2143	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2144	the federal or supplemental rebate, or both, equals or exceeds
2145	29 percent. There is no upper limit on the supplemental rebates
2146	the agency may negotiate. The agency may determine that specific
2147	products, brand-name or generic, are competitive at lower rebate
2148	percentages. Agreement to pay the minimum supplemental rebate
2149	percentage will guarantee a manufacturer that the Medicaid
2150	Pharmaceutical and Therapeutics Committee will consider a
2151	product for inclusion on the preferred drug list. However, a
2152	pharmaceutical manufacturer is not guaranteed placement on the
2153	preferred drug list by simply paying the minimum supplemental
2154	rebate. Agency decisions will be made on the clinical efficacy
2155	of a drug and recommendations of the Medicaid Pharmaceutical and
2156	Therapeutics Committee, as well as the price of competing
2157	products minus federal and state rebates. The agency is
2158	authorized to contract with an outside agency or contractor to
2159	conduct negotiations for supplemental rebates. For the purposes
2160	of this section, the term "supplemental rebates" means cash
2161	rebates. Effective July 1, 2004, value-added programs as a
2162	substitution for supplemental rebates are prohibited. The agency
2163	is authorized to seek any federal waivers to implement this
2164	initiative.
2165	8.  The Agency for Health Care Administration shall expand
2166	home delivery of pharmacy products. To assist Medicaid patients
2167	in securing their prescriptions and reduce program costs, the
2168	agency shall expand its current mail-order-pharmacy diabetes-
2169	supply program to include all generic and brand-name drugs used
2170	by Medicaid patients with diabetes. Medicaid recipients in the
2171	current program may obtain nondiabetes drugs on a voluntary
2172	basis. This initiative is limited to the geographic area covered
2173	by the current contract. The agency may seek and implement any
2174	federal waivers necessary to implement this subparagraph.
2175	9.  The agency shall limit to one dose per month any drug
2176	prescribed to treat erectile dysfunction.
2177	10.a.  The agency may implement a Medicaid behavioral drug
2178	management system. The agency may contract with a vendor that
2179	has experience in operating behavioral drug management systems
2180	to implement this program. The agency is authorized to seek
2181	federal waivers to implement this program.
2182	b.  The agency, in conjunction with the Department of
2183	Children and Family Services, may implement the Medicaid
2184	behavioral drug management system that is designed to improve
2185	the quality of care and behavioral health prescribing practices
2186	based on best practice guidelines, improve patient adherence to
2187	medication plans, reduce clinical risk, and lower prescribed
2188	drug costs and the rate of inappropriate spending on Medicaid
2189	behavioral drugs. The program may include the following
2190	elements:
2191	(I)  Provide for the development and adoption of best
2192	practice guidelines for behavioral health-related drugs such as
2193	antipsychotics, antidepressants, and medications for treating
2194	bipolar disorders and other behavioral conditions; translate
2195	them into practice; review behavioral health prescribers and
2196	compare their prescribing patterns to a number of indicators
2197	that are based on national standards; and determine deviations
2198	from best practice guidelines.
2199	(II)  Implement processes for providing feedback to and
2200	educating prescribers using best practice educational materials
2201	and peer-to-peer consultation.
2202	(III)  Assess Medicaid beneficiaries who are outliers in
2203	their use of behavioral health drugs with regard to the numbers
2204	and types of drugs taken, drug dosages, combination drug
2205	therapies, and other indicators of improper use of behavioral
2206	health drugs.
2207	(IV)  Alert prescribers to patients who fail to refill
2208	prescriptions in a timely fashion, are prescribed multiple same-
2209	class behavioral health drugs, and may have other potential
2210	medication problems.
2211	(V)  Track spending trends for behavioral health drugs and
2212	deviation from best practice guidelines.
2213	(VI)  Use educational and technological approaches to
2214	promote best practices, educate consumers, and train prescribers
2215	in the use of practice guidelines.
2216	(VII)  Disseminate electronic and published materials.
2217	(VIII)  Hold statewide and regional conferences.
2218	(IX)  Implement a disease management program with a model
2219	quality-based medication component for severely mentally ill
2220	individuals and emotionally disturbed children who are high
2221	users of care.
2222	11.a.  The agency shall implement a Medicaid prescription
2223	drug management system. The agency may contract with a vendor
2224	that has experience in operating prescription drug management
2225	systems in order to implement this system. Any management system
2226	that is implemented in accordance with this subparagraph must
2227	rely on cooperation between physicians and pharmacists to
2228	determine appropriate practice patterns and clinical guidelines
2229	to improve the prescribing, dispensing, and use of drugs in the
2230	Medicaid program. The agency may seek federal waivers to
2231	implement this program.
2232	b.  The drug management system must be designed to improve
2233	the quality of care and prescribing practices based on best
2234	practice guidelines, improve patient adherence to medication
2235	plans, reduce clinical risk, and lower prescribed drug costs and
2236	the rate of inappropriate spending on Medicaid prescription
2237	drugs. The program must:
2238	(I)  Provide for the development and adoption of best
2239	practice guidelines for the prescribing and use of drugs in the
2240	Medicaid program, including translating best practice guidelines
2241	into practice; reviewing prescriber patterns and comparing them
2242	to indicators that are based on national standards and practice
2243	patterns of clinical peers in their community, statewide, and
2244	nationally; and determine deviations from best practice
2245	guidelines.
2246	(II)  Implement processes for providing feedback to and
2247	educating prescribers using best practice educational materials
2248	and peer-to-peer consultation.
2249	(III)  Assess Medicaid recipients who are outliers in their
2250	use of a single or multiple prescription drugs with regard to
2251	the numbers and types of drugs taken, drug dosages, combination
2252	drug therapies, and other indicators of improper use of
2253	prescription drugs.
2254	(IV)  Alert prescribers to patients who fail to refill
2255	prescriptions in a timely fashion, are prescribed multiple drugs
2256	that may be redundant or contraindicated, or may have other
2257	potential medication problems.
2258	(V)  Track spending trends for prescription drugs and
2259	deviation from best practice guidelines.
2260	(VI)  Use educational and technological approaches to
2261	promote best practices, educate consumers, and train prescribers
2262	in the use of practice guidelines.
2263	(VII)  Disseminate electronic and published materials.
2264	(VIII)  Hold statewide and regional conferences.
2265	(IX)  Implement disease management programs in cooperation
2266	with physicians and pharmacists, along with a model quality-
2267	based medication component for individuals having chronic
2268	medical conditions.
2269	12.  The agency is authorized to contract for drug rebate
2270	administration, including, but not limited to, calculating
2271	rebate amounts, invoicing manufacturers, negotiating disputes
2272	with manufacturers, and maintaining a database of rebate
2273	collections.
2274	13.  The agency may specify the preferred daily dosing form
2275	or strength for the purpose of promoting best practices with
2276	regard to the prescribing of certain drugs as specified in the
2277	General Appropriations Act and ensuring cost-effective
2278	prescribing practices.
2279	14.  The agency may require prior authorization for
2280	Medicaid-covered prescribed drugs. The agency may, but is not
2281	required to, prior-authorize the use of a product:
2282	a.  For an indication not approved in labeling;
2283	b.  To comply with certain clinical guidelines; or
2284	c.  If the product has the potential for overuse, misuse,
2285	or abuse.
2286
2287	The agency may require the prescribing professional to provide
2288	information about the rationale and supporting medical evidence
2289	for the use of a drug. The agency may post prior authorization
2290	criteria and protocol and updates to the list of drugs that are
2291	subject to prior authorization on an Internet website without
2292	amending its rule or engaging in additional rulemaking.
2293	15.  The agency, in conjunction with the Pharmaceutical and
2294	Therapeutics Committee, may require age-related prior
2295	authorizations for certain prescribed drugs. The agency may
2296	preauthorize the use of a drug for a recipient who may not meet
2297	the age requirement or may exceed the length of therapy for use
2298	of this product as recommended by the manufacturer and approved
2299	by the Food and Drug Administration. Prior authorization may
2300	require the prescribing professional to provide information
2301	about the rationale and supporting medical evidence for the use
2302	of a drug.
2303	16.  The agency shall implement a step-therapy prior
2304	authorization approval process for medications excluded from the
2305	preferred drug list. Medications listed on the preferred drug
2306	list must be used within the previous 12 months prior to the
2307	alternative medications that are not listed. The step-therapy
2308	prior authorization may require the prescriber to use the
2309	medications of a similar drug class or for a similar medical
2310	indication unless contraindicated in the Food and Drug
2311	Administration labeling. The trial period between the specified
2312	steps may vary according to the medical indication. The step-
2313	therapy approval process shall be developed in accordance with
2314	the committee as stated in s. 409.91195(7) and (8). A drug
2315	product may be approved without meeting the step-therapy prior
2316	authorization criteria if the prescribing physician provides the
2317	agency with additional written medical or clinical documentation
2318	that the product is medically necessary because:
2319	a.  There is not a drug on the preferred drug list to treat
2320	the disease or medical condition which is an acceptable clinical
2321	alternative;
2322	b.  The alternatives have been ineffective in the treatment
2323	of the beneficiary's disease; or
2324	c.  Based on historic evidence and known characteristics of
2325	the patient and the drug, the drug is likely to be ineffective,
2326	or the number of doses have been ineffective.
2327
2328	The agency shall work with the physician to determine the best
2329	alternative for the patient. The agency may adopt rules waiving
2330	the requirements for written clinical documentation for specific
2331	drugs in limited clinical situations.
2332	17.  The agency shall implement a return and reuse program
2333	for drugs dispensed by pharmacies to institutional recipients,
2334	which includes payment of a $5 restocking fee for the
2335	implementation and operation of the program. The return and
2336	reuse program shall be implemented electronically and in a
2337	manner that promotes efficiency. The program must permit a
2338	pharmacy to exclude drugs from the program if it is not
2339	practical or cost-effective for the drug to be included and must
2340	provide for the return to inventory of drugs that cannot be
2341	credited or returned in a cost-effective manner. The agency
2342	shall determine if the program has reduced the amount of
2343	Medicaid prescription drugs which are destroyed on an annual
2344	basis and if there are additional ways to ensure more
2345	prescription drugs are not destroyed which could safely be
2346	reused. The agency's conclusion and recommendations shall be
2347	reported to the Legislature by December 1, 2005.
2348	(b)  The agency shall implement this subsection to the
2349	extent that funds are appropriated to administer the Medicaid
2350	prescribed-drug spending-control program. The agency may
2351	contract all or any part of this program to private
2352	organizations.
2353	(c)  The agency shall submit quarterly reports to the
2354	Governor, the President of the Senate, and the Speaker of the
2355	House of Representatives which must include, but need not be
2356	limited to, the progress made in implementing this subsection
2357	and its effect on Medicaid prescribed-drug expenditures.
2358	(38)(40)  Notwithstanding the provisions of chapter 287,
2359	the agency may, at its discretion, renew a contract or contracts
2360	for fiscal intermediary services one or more times for such
2361	periods as the agency may decide; however, all such renewals may
2362	not combine to exceed a total period longer than the term of the
2363	original contract.
2364	(39)(41)  The agency shall provide for the development of a
2365	demonstration project by establishment in Miami-Dade County of a
2366	long-term-care facility licensed pursuant to chapter 395 to
2367	improve access to health care for a predominantly minority,
2368	medically underserved, and medically complex population and to
2369	evaluate alternatives to nursing home care and general acute
2370	care for such population. Such project is to be located in a
2371	health care condominium and colocated with licensed facilities
2372	providing a continuum of care. The establishment of this project
2373	is not subject to the provisions of s. 408.036 or s. 408.039.
2374	This subsection expires October 1, 2013.
2375	(40)(42)  The agency shall develop and implement a
2376	utilization management program for Medicaid-eligible recipients
2377	for the management of occupational, physical, respiratory, and
2378	speech therapies. The agency shall establish a utilization
2379	program that may require prior authorization in order to ensure
2380	medically necessary and cost-effective treatments. The program
2381	shall be operated in accordance with a federally approved waiver
2382	program or state plan amendment. The agency may seek a federal
2383	waiver or state plan amendment to implement this program. The
2384	agency may also competitively procure these services from an
2385	outside vendor on a regional or statewide basis. This subsection
2386	expires October 1, 2014.
2387	(41)(43)  The agency shall may contract on a prepaid or
2388	fixed-sum basis with appropriately licensed prepaid dental
2389	health plans to provide dental services. This subsection expires
2390	October 1, 2014.
2391	(42)(44)  The Agency for Health Care Administration shall
2392	ensure that any Medicaid managed care plan as defined in s.
2393	409.9122(2)(f), whether paid on a capitated basis or a shared
2394	savings basis, is cost-effective. For purposes of this
2395	subsection, the term "cost-effective" means that a network's
2396	per-member, per-month costs to the state, including, but not
2397	limited to, fee-for-service costs, administrative costs, and
2398	case-management fees, if any, must be no greater than the
2399	state's costs associated with contracts for Medicaid services
2400	established under subsection (3), which may be adjusted for
2401	health status. The agency shall conduct actuarially sound
2402	adjustments for health status in order to ensure such cost-
2403	effectiveness and shall annually publish the results on its
2404	Internet website. Contracts established pursuant to this
2405	subsection which are not cost-effective may not be renewed. This
2406	subsection expires October 1, 2014.
2407	(43)(45)  Subject to the availability of funds, the agency
2408	shall mandate a recipient's participation in a provider lock-in
2409	program, when appropriate, if a recipient is found by the agency
2410	to have used Medicaid goods or services at a frequency or amount
2411	not medically necessary, limiting the receipt of goods or
2412	services to medically necessary providers after the 21-day
2413	appeal process has ended, for a period of not less than 1 year.
2414	The lock-in programs shall include, but are not limited to,
2415	pharmacies, medical doctors, and infusion clinics. The
2416	limitation does not apply to emergency services and care
2417	provided to the recipient in a hospital emergency department.
2418	The agency shall seek any federal waivers necessary to implement
2419	this subsection. The agency shall adopt any rules necessary to
2420	comply with or administer this subsection. This subsection
2421	expires October 1, 2014.
2422	(44)(46)  The agency shall seek a federal waiver for
2423	permission to terminate the eligibility of a Medicaid recipient
2424	who has been found to have committed fraud, through judicial or
2425	administrative determination, two times in a period of 5 years.
2426	(47)  The agency shall conduct a study of available
2427	electronic systems for the purpose of verifying the identity and
2428	eligibility of a Medicaid recipient. The agency shall recommend
2429	to the Legislature a plan to implement an electronic
2430	verification system for Medicaid recipients by January 31, 2005.
2431	(45)(48)(a)  A provider is not entitled to enrollment in
2432	the Medicaid provider network. The agency may implement a
2433	Medicaid fee-for-service provider network controls, including,
2434	but not limited to, competitive procurement and provider
2435	credentialing. If a credentialing process is used, the agency
2436	may limit its provider network based upon the following
2437	considerations: beneficiary access to care, provider
2438	availability, provider quality standards and quality assurance
2439	processes, cultural competency, demographic characteristics of
2440	beneficiaries, practice standards, service wait times, provider
2441	turnover, provider licensure and accreditation history, program
2442	integrity history, peer review, Medicaid policy and billing
2443	compliance records, clinical and medical record audit findings,
2444	and such other areas that are considered necessary by the agency
2445	to ensure the integrity of the program.
2446	(b)  The agency shall limit its network of durable medical
2447	equipment and medical supply providers. For dates of service
2448	after January 1, 2009, the agency shall limit payment for
2449	durable medical equipment and supplies to providers that meet
2450	all the requirements of this paragraph.
2451	1.  Providers must be accredited by a Centers for Medicare
2452	and Medicaid Services deemed accreditation organization for
2453	suppliers of durable medical equipment, prosthetics, orthotics,
2454	and supplies. The provider must maintain accreditation and is
2455	subject to unannounced reviews by the accrediting organization.
2456	2.  Providers must provide the services or supplies
2457	directly to the Medicaid recipient or caregiver at the provider
2458	location or recipient's residence or send the supplies directly
2459	to the recipient's residence with receipt of mailed delivery.
2460	Subcontracting or consignment of the service or supply to a
2461	third party is prohibited.
2462	3.  Notwithstanding subparagraph 2., a durable medical
2463	equipment provider may store nebulizers at a physician's office
2464	for the purpose of having the physician's staff issue the
2465	equipment if it meets all of the following conditions:
2466	a.  The physician must document the medical necessity and
2467	need to prevent further deterioration of the patient's
2468	respiratory status by the timely delivery of the nebulizer in
2469	the physician's office.
2470	b.  The durable medical equipment provider must have
2471	written documentation of the competency and training by a
2472	Florida-licensed registered respiratory therapist of any durable
2473	medical equipment staff who participate in the training of
2474	physician office staff for the use of nebulizers, including
2475	cleaning, warranty, and special needs of patients.
2476	c.  The physician's office must have documented the
2477	training and competency of any staff member who initiates the
2478	delivery of nebulizers to patients. The durable medical
2479	equipment provider must maintain copies of all physician office
2480	training.
2481	d.  The physician's office must maintain inventory records
2482	of stored nebulizers, including documentation of the durable
2483	medical equipment provider source.
2484	e.  A physician contracted with a Medicaid durable medical
2485	equipment provider may not have a financial relationship with
2486	that provider or receive any financial gain from the delivery of
2487	nebulizers to patients.
2488	4.  Providers must have a physical business location and a
2489	functional landline business phone. The location must be within
2490	the state or not more than 50 miles from the Florida state line.
2491	The agency may make exceptions for providers of durable medical
2492	equipment or supplies not otherwise available from other
2493	enrolled providers located within the state.
2494	5.  Physical business locations must be clearly identified
2495	as a business that furnishes durable medical equipment or
2496	medical supplies by signage that can be read from 20 feet away.
2497	The location must be readily accessible to the public during
2498	normal, posted business hours and must operate at least 5 hours
2499	per day and at least 5 days per week, with the exception of
2500	scheduled and posted holidays. The location may not be located
2501	within or at the same numbered street address as another
2502	enrolled Medicaid durable medical equipment or medical supply
2503	provider or as an enrolled Medicaid pharmacy that is also
2504	enrolled as a durable medical equipment provider. A licensed
2505	orthotist or prosthetist that provides only orthotic or
2506	prosthetic devices as a Medicaid durable medical equipment
2507	provider is exempt from this paragraph.
2508	6.  Providers must maintain a stock of durable medical
2509	equipment and medical supplies on site that is readily available
2510	to meet the needs of the durable medical equipment business
2511	location's customers.
2512	7.  Providers must provide a surety bond of $50,000 for
2513	each provider location, up to a maximum of 5 bonds statewide or
2514	an aggregate bond of $250,000 statewide, as identified by
2515	Federal Employer Identification Number. Providers who post a
2516	statewide or an aggregate bond must identify all of their
2517	locations in any Medicaid durable medical equipment and medical
2518	supply provider enrollment application or bond renewal. Each
2519	provider location's surety bond must be renewed annually and the
2520	provider must submit proof of renewal even if the original bond
2521	is a continuous bond. A licensed orthotist or prosthetist that
2522	provides only orthotic or prosthetic devices as a Medicaid
2523	durable medical equipment provider is exempt from the provisions
2524	in this paragraph.
2525	8.  Providers must obtain a level 2 background screening,
2526	in accordance with chapter 435 and s. 408.809, for each provider
2527	employee in direct contact with or providing direct services to
2528	recipients of durable medical equipment and medical supplies in
2529	their homes. This requirement includes, but is not limited to,
2530	repair and service technicians, fitters, and delivery staff. The
2531	provider shall pay for the cost of the background screening.
2532	9.  The following providers are exempt from subparagraphs
2533	1. and 7.:
2534	a.  Durable medical equipment providers owned and operated
2535	by a government entity.
2536	b.  Durable medical equipment providers that are operating
2537	within a pharmacy that is currently enrolled as a Medicaid
2538	pharmacy provider.
2539	c.  Active, Medicaid-enrolled orthopedic physician groups,
2540	primarily owned by physicians, which provide only orthotic and
2541	prosthetic devices.
2542	(46)(49)  The agency shall contract with established
2543	minority physician networks that provide services to
2544	historically underserved minority patients. The networks must
2545	provide cost-effective Medicaid services, comply with the
2546	requirements to be a MediPass provider, and provide their
2547	primary care physicians with access to data and other management
2548	tools necessary to assist them in ensuring the appropriate use
2549	of services, including inpatient hospital services and
2550	pharmaceuticals.
2551	(a)  The agency shall provide for the development and
2552	expansion of minority physician networks in each service area to
2553	provide services to Medicaid recipients who are eligible to
2554	participate under federal law and rules.
2555	(b)  The agency shall reimburse each minority physician
2556	network as a fee-for-service provider, including the case
2557	management fee for primary care, if any, or as a capitated rate
2558	provider for Medicaid services. Any savings shall be shared with
2559	the minority physician networks pursuant to the contract.
2560	(c)  For purposes of this subsection, the term "cost-
2561	effective" means that a network's per-member, per-month costs to
2562	the state, including, but not limited to, fee-for-service costs,
2563	administrative costs, and case-management fees, if any, must be
2564	no greater than the state's costs associated with contracts for
2565	Medicaid services established under subsection (3), which shall
2566	be actuarially adjusted for case mix, model, and service area.
2567	The agency shall conduct actuarially sound audits adjusted for
2568	case mix and model in order to ensure such cost-effectiveness
2569	and shall annually publish the audit results on its Internet
2570	website. Contracts established pursuant to this subsection which
2571	are not cost-effective may not be renewed.
2572	(d)  The agency may apply for any federal waivers needed to
2573	implement this subsection.
2574
2575	This subsection expires October 1, 2014.
2576	(47)(50)  To the extent permitted by federal law and as
2577	allowed under s. 409.906, the agency shall provide reimbursement
2578	for emergency mental health care services for Medicaid
2579	recipients in crisis stabilization facilities licensed under s.
2580	394.875 as long as those services are less expensive than the
2581	same services provided in a hospital setting.
2582	(48)(51)  The agency shall work with the Agency for Persons
2583	with Disabilities to develop a home and community-based waiver
2584	to serve children and adults who are diagnosed with familial
2585	dysautonomia or Riley-Day syndrome caused by a mutation of the
2586	IKBKAP gene on chromosome 9. The agency shall seek federal
2587	waiver approval and implement the approved waiver subject to the
2588	availability of funds and any limitations provided in the
2589	General Appropriations Act. The agency may adopt rules to
2590	implement this waiver program.
2591	(49)(52)  The agency shall implement a program of all-
2592	inclusive care for children. The program of all-inclusive care
2593	for children shall be established to provide in-home hospice-
2594	like support services to children diagnosed with a life-
2595	threatening illness and enrolled in the Children's Medical
2596	Services network to reduce hospitalizations as appropriate. The
2597	agency, in consultation with the Department of Health, may
2598	implement the program of all-inclusive care for children after
2599	obtaining approval from the Centers for Medicare and Medicaid
2600	Services.
2601	(50)(53)  Before seeking an amendment to the state plan for
2602	purposes of implementing programs authorized by the Deficit
2603	Reduction Act of 2005, the agency shall notify the Legislature.
2604	Section 14.  Section 409.91207, Florida Statutes, is
2605	repealed.
2606	Section 15.  Paragraphs (e), (l), (p), (w), and (dd) of
2607	subsection (3) of section 409.91211, Florida Statutes, are
2608	amended to read:
2609	409.91211  Medicaid managed care pilot program.-
2610	(3)  The agency shall have the following powers, duties,
2611	and responsibilities with respect to the pilot program:
2612	(e)  To implement policies and guidelines for phasing in
2613	financial risk for approved provider service networks that, for
2614	purposes of this paragraph, include the Children's Medical
2615	Services Network, over the period of the waiver and the
2616	extension thereof. These policies and guidelines must include an
2617	option for a provider service network to be paid fee-for-service
2618	rates. For any provider service network established in a managed
2619	care pilot area, the option to be paid fee-for-service rates
2620	must include a savings-settlement mechanism that is consistent
2621	with s. 409.912(42)(44). This model must be converted to a risk-
2622	adjusted capitated rate by the beginning of the final year of
2623	operation under the waiver extension, and may be converted
2624	earlier at the option of the provider service network. Federally
2625	qualified health centers may be offered an opportunity to accept
2626	or decline a contract to participate in any provider network for
2627	prepaid primary care services.
2628	(l)  To implement a system that prohibits capitated managed
2629	care plans, their representatives, and providers employed by or
2630	contracted with the capitated managed care plans from recruiting
2631	persons eligible for or enrolled in Medicaid, from providing
2632	inducements to Medicaid recipients to select a particular
2633	capitated managed care plan, and from prejudicing Medicaid
2634	recipients against other capitated managed care plans. The
2635	system shall require the entity performing choice counseling to
2636	determine if the recipient has made a choice of a plan or has
2637	opted out because of duress, threats, payment to the recipient,
2638	or incentives promised to the recipient by a third party. If the
2639	choice counseling entity determines that the decision to choose
2640	a plan was unlawfully influenced or a plan violated any of the
2641	provisions of s. 409.912(20)(21), the choice counseling entity
2642	shall immediately report the violation to the agency's program
2643	integrity section for investigation. Verification of choice
2644	counseling by the recipient shall include a stipulation that the
2645	recipient acknowledges the provisions of this subsection.
2646	(p)  To implement standards for plan compliance, including,
2647	but not limited to, standards for quality assurance and
2648	performance improvement, standards for peer or professional
2649	reviews, grievance policies, and policies for maintaining
2650	program integrity. The agency shall develop a data-reporting
2651	system, seek input from managed care plans in order to establish
2652	requirements for patient-encounter reporting, and ensure that
2653	the data reported is accurate and complete.
2654	1.  In performing the duties required under this section,
2655	the agency shall work with managed care plans to establish a
2656	uniform system to measure and monitor outcomes for a recipient
2657	of Medicaid services.
2658	2.  The system shall use financial, clinical, and other
2659	criteria based on pharmacy, medical services, and other data
2660	that is related to the provision of Medicaid services,
2661	including, but not limited to:
2662	a.  The Health Plan Employer Data and Information Set
2663	(HEDIS) or measures that are similar to HEDIS.
2664	b.  Member satisfaction.
2665	c.  Provider satisfaction.
2666	d.  Report cards on plan performance and best practices.
2667	e.  Compliance with the requirements for prompt payment of
2668	claims under ss. 627.613, 641.3155, and 641.513.
2669	f.  Utilization and quality data for the purpose of
2670	ensuring access to medically necessary services, including
2671	underutilization or inappropriate denial of services.
2672	3.  The agency shall require the managed care plans that
2673	have contracted with the agency to establish a quality assurance
2674	system that incorporates the provisions of s. 409.912(26)(27)
2675	and any standards, rules, and guidelines developed by the
2676	agency.
2677	4.  The agency shall establish an encounter database in
2678	order to compile data on health services rendered by health care
2679	practitioners who provide services to patients enrolled in
2680	managed care plans in the demonstration sites. The encounter
2681	database shall:
2682	a.  Collect the following for each type of patient
2683	encounter with a health care practitioner or facility,
2684	including:
2685	(I)  The demographic characteristics of the patient.
2686	(II)  The principal, secondary, and tertiary diagnosis.
2687	(III)  The procedure performed.
2688	(IV)  The date and location where the procedure was
2689	performed.
2690	(V)  The payment for the procedure, if any.
2691	(VI)  If applicable, the health care practitioner's
2692	universal identification number.
2693	(VII)  If the health care practitioner rendering the
2694	service is a dependent practitioner, the modifiers appropriate
2695	to indicate that the service was delivered by the dependent
2696	practitioner.
2697	b.  Collect appropriate information relating to
2698	prescription drugs for each type of patient encounter.
2699	c.  Collect appropriate information related to health care
2700	costs and utilization from managed care plans participating in
2701	the demonstration sites.
2702	5.  To the extent practicable, when collecting the data the
2703	agency shall use a standardized claim form or electronic
2704	transfer system that is used by health care practitioners,
2705	facilities, and payors.
2706	6.  Health care practitioners and facilities in the
2707	demonstration sites shall electronically submit, and managed
2708	care plans participating in the demonstration sites shall
2709	electronically receive, information concerning claims payments
2710	and any other information reasonably related to the encounter
2711	database using a standard format as required by the agency.
2712	7.  The agency shall establish reasonable deadlines for
2713	phasing in the electronic transmittal of full encounter data.
2714	8.  The system must ensure that the data reported is
2715	accurate and complete.
2716	(w)  To implement procedures to minimize the risk of
2717	Medicaid fraud and abuse in all plans operating in the Medicaid
2718	managed care pilot program authorized in this section.
2719	1.  The agency shall ensure that applicable provisions of
2720	this chapter and chapters 414, 626, 641, and 932 which relate to
2721	Medicaid fraud and abuse are applied and enforced at the
2722	demonstration project sites.
2723	2.  Providers must have the certification, license, and
2724	credentials that are required by law and waiver requirements.
2725	3.  The agency shall ensure that the plan is in compliance
2726	with s. 409.912(20) and (21) and (22).
2727	4.  The agency shall require that each plan establish
2728	functions and activities governing program integrity in order to
2729	reduce the incidence of fraud and abuse. Plans must report
2730	instances of fraud and abuse pursuant to chapter 641.
2731	5.  The plan shall have written administrative and
2732	management arrangements or procedures, including a mandatory
2733	compliance plan, which are designed to guard against fraud and
2734	abuse. The plan shall designate a compliance officer who has
2735	sufficient experience in health care.
2736	6.a.  The agency shall require all managed care plan
2737	contractors in the pilot program to report all instances of
2738	suspected fraud and abuse. A failure to report instances of
2739	suspected fraud and abuse is a violation of law and subject to
2740	the penalties provided by law.
2741	b.  An instance of fraud and abuse in the managed care
2742	plan, including, but not limited to, defrauding the state health
2743	care benefit program by misrepresentation of fact in reports,
2744	claims, certifications, enrollment claims, demographic
2745	statistics, or patient-encounter data; misrepresentation of the
2746	qualifications of persons rendering health care and ancillary
2747	services; bribery and false statements relating to the delivery
2748	of health care; unfair and deceptive marketing practices; and
2749	false claims actions in the provision of managed care, is a
2750	violation of law and subject to the penalties provided by law.
2751	c.  The agency shall require that all contractors make all
2752	files and relevant billing and claims data accessible to state
2753	regulators and investigators and that all such data is linked
2754	into a unified system to ensure consistent reviews and
2755	investigations.
2756	(dd)  To implement service delivery mechanisms within a
2757	specialty plan in area 10 to provide behavioral health care
2758	services to Medicaid-eligible children whose cases are open for
2759	child welfare services in the HomeSafeNet system. These services
2760	must be coordinated with community-based care providers as
2761	specified in s. 409.1671, where available, and be sufficient to
2762	meet the developmental, behavioral, and emotional needs of these
2763	children. Children in area 10 who have an open case in the
2764	HomeSafeNet system shall be enrolled into the specialty plan.
2765	These service delivery mechanisms must be implemented no later
2766	than July 1, 2011, in AHCA area 10 in order for the children in
2767	AHCA area 10 to remain exempt from the statewide plan under s.
2768	409.912(4)(b)5.8. An administrative fee may be paid to the
2769	specialty plan for the coordination of services based on the
2770	receipt of the state share of that fee being provided through
2771	intergovernmental transfers.
2772	Section 16.  Effective October 1, 2014, section 409.91211,
2773	Florida Statutes, is repealed.
2774	Section 17.  Section 409.9122, Florida Statutes, is amended
2775	to read:
2776	409.9122  Mandatory Medicaid managed care enrollment;
2777	programs and procedures.-
2778	(1)  It is the intent of the Legislature that the MediPass
2779	program be cost-effective, provide quality health care, and
2780	improve access to health services, and that the program be
2781	statewide. This subsection expires October 1, 2014.
2782	(2)(a)  The agency shall enroll in a managed care plan or
2783	MediPass all Medicaid recipients, except those Medicaid
2784	recipients who are: in an institution; enrolled in the Medicaid
2785	medically needy program; or eligible for both Medicaid and
2786	Medicare. Upon enrollment, individuals will be able to change
2787	their managed care option during the 90-day opt out period
2788	required by federal Medicaid regulations. The agency is
2789	authorized to seek the necessary Medicaid state plan amendment
2790	to implement this policy. However, to the extent permitted by
2791	federal law, the agency may enroll in a managed care plan or
2792	MediPass a Medicaid recipient who is exempt from mandatory
2793	managed care enrollment, provided that:
2794	1.  The recipient's decision to enroll in a managed care
2795	plan or MediPass is voluntary;
2796	2.  If the recipient chooses to enroll in a managed care
2797	plan, the agency has determined that the managed care plan
2798	provides specific programs and services which address the
2799	special health needs of the recipient; and
2800	3.  The agency receives any necessary waivers from the
2801	federal Centers for Medicare and Medicaid Services.
2802
2803	The agency shall develop rules to establish policies by which
2804	exceptions to the mandatory managed care enrollment requirement
2805	may be made on a case-by-case basis. The rules shall include the
2806	specific criteria to be applied when making a determination as
2807	to whether to exempt a recipient from mandatory enrollment in a
2808	managed care plan or MediPass. School districts participating in
2809	the certified school match program pursuant to ss. 409.908(21)
2810	and 1011.70 shall be reimbursed by Medicaid, subject to the
2811	limitations of s. 1011.70(1), for a Medicaid-eligible child
2812	participating in the services as authorized in s. 1011.70, as
2813	provided for in s. 409.9071, regardless of whether the child is
2814	enrolled in MediPass or a managed care plan. Managed care plans
2815	shall make a good faith effort to execute agreements with school
2816	districts regarding the coordinated provision of services
2817	authorized under s. 1011.70. County health departments
2818	delivering school-based services pursuant to ss. 381.0056 and
2819	381.0057 shall be reimbursed by Medicaid for the federal share
2820	for a Medicaid-eligible child who receives Medicaid-covered
2821	services in a school setting, regardless of whether the child is
2822	enrolled in MediPass or a managed care plan. Managed care plans
2823	shall make a good faith effort to execute agreements with county
2824	health departments regarding the coordinated provision of
2825	services to a Medicaid-eligible child. To ensure continuity of
2826	care for Medicaid patients, the agency, the Department of
2827	Health, and the Department of Education shall develop procedures
2828	for ensuring that a student's managed care plan or MediPass
2829	provider receives information relating to services provided in
2830	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2831	(b)  A Medicaid recipient shall not be enrolled in or
2832	assigned to a managed care plan or MediPass unless the managed
2833	care plan or MediPass has complied with the quality-of-care
2834	standards specified in paragraphs (3)(a) and (b), respectively.
2835	(c)  Medicaid recipients shall have a choice of managed
2836	care plans or MediPass. The Agency for Health Care
2837	Administration, the Department of Health, the Department of
2838	Children and Family Services, and the Department of Elderly
2839	Affairs shall cooperate to ensure that each Medicaid recipient
2840	receives clear and easily understandable information that meets
2841	the following requirements:
2842	1.  Explains the concept of managed care, including
2843	MediPass.
2844	2.  Provides information on the comparative performance of
2845	managed care plans and MediPass in the areas of quality,
2846	credentialing, preventive health programs, network size and
2847	availability, and patient satisfaction.
2848	3.  Explains where additional information on each managed
2849	care plan and MediPass in the recipient's area can be obtained.
2850	4.  Explains that recipients have the right to choose their
2851	managed care coverage at the time they first enroll in Medicaid
2852	and again at regular intervals set by the agency. However, if a
2853	recipient does not choose a managed care plan or MediPass, the
2854	agency will assign the recipient to a managed care plan or
2855	MediPass according to the criteria specified in this section.
2856	5.  Explains the recipient's right to complain, file a
2857	grievance, or change managed care plans or MediPass providers if
2858	the recipient is not satisfied with the managed care plan or
2859	MediPass.
2860	(d)  The agency shall develop a mechanism for providing
2861	information to Medicaid recipients for the purpose of making a
2862	managed care plan or MediPass selection. Examples of such
2863	mechanisms may include, but not be limited to, interactive
2864	information systems, mailings, and mass marketing materials.
2865	Managed care plans and MediPass providers are prohibited from
2866	providing inducements to Medicaid recipients to select their
2867	plans or from prejudicing Medicaid recipients against other
2868	managed care plans or MediPass providers.
2869	(e)  Medicaid recipients who are already enrolled in a
2870	managed care plan or MediPass shall be offered the opportunity
2871	to change managed care plans or MediPass providers on a
2872	staggered basis, as defined by the agency. All Medicaid
2873	recipients shall have 30 days in which to make a choice of
2874	managed care plans or MediPass providers. Those Medicaid
2875	recipients who do not make a choice shall be assigned in
2876	accordance with paragraph (f). To facilitate continuity of care,
2877	for a Medicaid recipient who is also a recipient of Supplemental
2878	Security Income (SSI), prior to assigning the SSI recipient to a
2879	managed care plan or MediPass, the agency shall determine
2880	whether the SSI recipient has an ongoing relationship with a
2881	MediPass provider or managed care plan, and if so, the agency
2882	shall assign the SSI recipient to that MediPass provider or
2883	managed care plan. Those SSI recipients who do not have such a
2884	provider relationship shall be assigned to a managed care plan
2885	or MediPass provider in accordance with paragraph (f).
2886	(f)  If a Medicaid recipient does not choose a managed care
2887	plan or MediPass provider, the agency shall assign the Medicaid
2888	recipient to a managed care plan or MediPass provider. Medicaid
2889	recipients eligible for managed care plan enrollment who are
2890	subject to mandatory assignment but who fail to make a choice
2891	shall be assigned to managed care plans until an enrollment of
2892	35 percent in MediPass and 65 percent in managed care plans, of
2893	all those eligible to choose managed care, is achieved. Once
2894	this enrollment is achieved, the assignments shall be divided in
2895	order to maintain an enrollment in MediPass and managed care
2896	plans which is in a 35 percent and 65 percent proportion,
2897	respectively. Thereafter, assignment of Medicaid recipients who
2898	fail to make a choice shall be based proportionally on the
2899	preferences of recipients who have made a choice in the previous
2900	period. Such proportions shall be revised at least quarterly to
2901	reflect an update of the preferences of Medicaid recipients. The
2902	agency shall disproportionately assign Medicaid-eligible
2903	recipients who are required to but have failed to make a choice
2904	of managed care plan or MediPass, including children, and who
2905	would be assigned to the MediPass program to the children's
2906	networks as described in s. 409.912(4)(g), Children's Medical
2907	Services Network as defined in s. 391.021, exclusive provider
2908	organizations, provider service networks, minority physician
2909	networks, and pediatric emergency department diversion programs
2910	authorized by this chapter or the General Appropriations Act, in
2911	such manner as the agency deems appropriate, until the agency
2912	has determined that the networks and programs have sufficient
2913	numbers to be operated economically. For purposes of this
2914	paragraph, when referring to assignment, the term "managed care
2915	plans" includes health maintenance organizations, exclusive
2916	provider organizations, provider service networks, minority
2917	physician networks, Children's Medical Services Network, and
2918	pediatric emergency department diversion programs authorized by
2919	this chapter or the General Appropriations Act. When making
2920	assignments, the agency shall take into account the following
2921	criteria:
2922	1.  A managed care plan has sufficient network capacity to
2923	meet the need of members.
2924	2.  The managed care plan or MediPass has previously
2925	enrolled the recipient as a member, or one of the managed care
2926	plan's primary care providers or MediPass providers has
2927	previously provided health care to the recipient.
2928	3.  The agency has knowledge that the member has previously
2929	expressed a preference for a particular managed care plan or
2930	MediPass provider as indicated by Medicaid fee-for-service
2931	claims data, but has failed to make a choice.
2932	4.  The managed care plan's or MediPass primary care
2933	providers are geographically accessible to the recipient's
2934	residence.
2935	(g)  When more than one managed care plan or MediPass
2936	provider meets the criteria specified in paragraph (f), the
2937	agency shall make recipient assignments consecutively by family
2938	unit.
2939	(h)  The agency may not engage in practices that are
2940	designed to favor one managed care plan over another or that are
2941	designed to influence Medicaid recipients to enroll in MediPass
2942	rather than in a managed care plan or to enroll in a managed
2943	care plan rather than in MediPass. This subsection does not
2944	prohibit the agency from reporting on the performance of
2945	MediPass or any managed care plan, as measured by performance
2946	criteria developed by the agency.
2947	(i)  After a recipient has made his or her selection or has
2948	been enrolled in a managed care plan or MediPass, the recipient
2949	shall have 90 days to exercise the opportunity to voluntarily
2950	disenroll and select another managed care plan or MediPass.
2951	After 90 days, no further changes may be made except for good
2952	cause. Good cause includes, but is not limited to, poor quality
2953	of care, lack of access to necessary specialty services, an
2954	unreasonable delay or denial of service, or fraudulent
2955	enrollment. The agency shall develop criteria for good cause
2956	disenrollment for chronically ill and disabled populations who
2957	are assigned to managed care plans if more appropriate care is
2958	available through the MediPass program. The agency must make a
2959	determination as to whether cause exists. However, the agency
2960	may require a recipient to use the managed care plan's or
2961	MediPass grievance process prior to the agency's determination
2962	of cause, except in cases in which immediate risk of permanent
2963	damage to the recipient's health is alleged. The grievance
2964	process, when utilized, must be completed in time to permit the
2965	recipient to disenroll by the first day of the second month
2966	after the month the disenrollment request was made. If the
2967	managed care plan or MediPass, as a result of the grievance
2968	process, approves an enrollee's request to disenroll, the agency
2969	is not required to make a determination in the case. The agency
2970	must make a determination and take final action on a recipient's
2971	request so that disenrollment occurs no later than the first day
2972	of the second month after the month the request was made. If the
2973	agency fails to act within the specified timeframe, the
2974	recipient's request to disenroll is deemed to be approved as of
2975	the date agency action was required. Recipients who disagree
2976	with the agency's finding that cause does not exist for
2977	disenrollment shall be advised of their right to pursue a
2978	Medicaid fair hearing to dispute the agency's finding.
2979	(j)  The agency shall apply for a federal waiver from the
2980	Centers for Medicare and Medicaid Services to lock eligible
2981	Medicaid recipients into a managed care plan or MediPass for 12
2982	months after an open enrollment period. After 12 months'
2983	enrollment, a recipient may select another managed care plan or
2984	MediPass provider. However, nothing shall prevent a Medicaid
2985	recipient from changing primary care providers within the
2986	managed care plan or MediPass program during the 12-month
2987	period.
2988	(k)  When a Medicaid recipient does not choose a managed
2989	care plan or MediPass provider, the agency shall assign the
2990	Medicaid recipient to a managed care plan, except in those
2991	counties in which there are fewer than two managed care plans
2992	accepting Medicaid enrollees, in which case assignment shall be
2993	to a managed care plan or a MediPass provider. Medicaid
2994	recipients in counties with fewer than two managed care plans
2995	accepting Medicaid enrollees who are subject to mandatory
2996	assignment but who fail to make a choice shall be assigned to
2997	managed care plans until an enrollment of 35 percent in MediPass
2998	and 65 percent in managed care plans, of all those eligible to
2999	choose managed care, is achieved. Once that enrollment is
3000	achieved, the assignments shall be divided in order to maintain
3001	an enrollment in MediPass and managed care plans which is in a
3002	35 percent and 65 percent proportion, respectively. For purposes
3003	of this paragraph, when referring to assignment, the term
3004	"managed care plans" includes exclusive provider organizations,
3005	provider service networks, Children's Medical Services Network,
3006	minority physician networks, and pediatric emergency department
3007	diversion programs authorized by this chapter or the General
3008	Appropriations Act. When making assignments, the agency shall
3009	take into account the following criteria:
3010	1.  A managed care plan has sufficient network capacity to
3011	meet the need of members.
3012	2.  The managed care plan or MediPass has previously
3013	enrolled the recipient as a member, or one of the managed care
3014	plan's primary care providers or MediPass providers has
3015	previously provided health care to the recipient.
3016	3.  The agency has knowledge that the member has previously
3017	expressed a preference for a particular managed care plan or
3018	MediPass provider as indicated by Medicaid fee-for-service
3019	claims data, but has failed to make a choice.
3020	4.  The managed care plan's or MediPass primary care
3021	providers are geographically accessible to the recipient's
3022	residence.
3023	5.  The agency has authority to make mandatory assignments
3024	based on quality of service and performance of managed care
3025	plans.
3026	(l)  Notwithstanding the provisions of chapter 287, the
3027	agency may, at its discretion, renew cost-effective contracts
3028	for choice counseling services once or more for such periods as
3029	the agency may decide. However, all such renewals may not
3030	combine to exceed a total period longer than the term of the
3031	original contract.
3032
3033	This subsection expires October 1, 2014.
3034	(3)(a)  The agency shall establish quality-of-care
3035	standards for managed care plans. These standards shall be based
3036	upon, but are not limited to:
3037	1.  Compliance with the accreditation requirements as
3038	provided in s. 641.512.
3039	2.  Compliance with Early and Periodic Screening,
3040	Diagnosis, and Treatment screening requirements.
3041	3.  The percentage of voluntary disenrollments.
3042	4.  Immunization rates.
3043	5.  Standards of the National Committee for Quality
3044	Assurance and other approved accrediting bodies.
3045	6.  Recommendations of other authoritative bodies.
3046	7.  Specific requirements of the Medicaid program, or
3047	standards designed to specifically assist the unique needs of
3048	Medicaid recipients.
3049	8.  Compliance with the health quality improvement system
3050	as established by the agency, which incorporates standards and
3051	guidelines developed by the Medicaid Bureau of the Health Care
3052	Financing Administration as part of the quality assurance reform
3053	initiative.
3054	(b)  For the MediPass program, the agency shall establish
3055	standards which are based upon, but are not limited to:
3056	1.  Quality-of-care standards which are comparable to those
3057	required of managed care plans.
3058	2.  Credentialing standards for MediPass providers.
3059	3.  Compliance with Early and Periodic Screening,
3060	Diagnosis, and Treatment screening requirements.
3061	4.  Immunization rates.
3062	5.  Specific requirements of the Medicaid program, or
3063	standards designed to specifically assist the unique needs of
3064	Medicaid recipients.
3065
3066	This subsection expires October 1, 2014.
3067	(4)(a)  Each female recipient may select as her primary
3068	care provider an obstetrician/gynecologist who has agreed to
3069	participate as a MediPass primary care case manager.
3070	(b)  The agency shall establish a complaints and grievance
3071	process to assist Medicaid recipients enrolled in the MediPass
3072	program to resolve complaints and grievances. The agency shall
3073	investigate reports of quality-of-care grievances which remain
3074	unresolved to the satisfaction of the enrollee.
3075
3076	This subsection expires October 1, 2014.
3077	(5)(a)  The agency shall work cooperatively with the Social
3078	Security Administration to identify beneficiaries who are
3079	jointly eligible for Medicare and Medicaid and shall develop
3080	cooperative programs to encourage these beneficiaries to enroll
3081	in a Medicare participating health maintenance organization or
3082	prepaid health plans.
3083	(b)  The agency shall work cooperatively with the
3084	Department of Elderly Affairs to assess the potential cost-
3085	effectiveness of providing MediPass to beneficiaries who are
3086	jointly eligible for Medicare and Medicaid on a voluntary choice
3087	basis. If the agency determines that enrollment of these
3088	beneficiaries in MediPass has the potential for being cost-
3089	effective for the state, the agency shall offer MediPass to
3090	these beneficiaries on a voluntary choice basis in the counties
3091	where MediPass operates.
3092
3093	This subsection expires October 1, 2014.
3094	(6)  MediPass enrolled recipients may receive up to 10
3095	visits of reimbursable services by participating Medicaid
3096	physicians licensed under chapter 460 and up to four visits of
3097	reimbursable services by participating Medicaid physicians
3098	licensed under chapter 461. Any further visits must be by prior
3099	authorization by the MediPass primary care provider. However,
3100	nothing in this subsection may be construed to increase the
3101	total number of visits or the total amount of dollars per year
3102	per person under current Medicaid rules, unless otherwise
3103	provided for in the General Appropriations Act. This subsection
3104	expires October 1, 2014.
3105	(7)  The agency shall investigate the feasibility of
3106	developing managed care plan and MediPass options for the
3107	following groups of Medicaid recipients:
3108	(a)  Pregnant women and infants.
3109	(b)  Elderly and disabled recipients, especially those who
3110	are at risk of nursing home placement.
3111	(c)  Persons with developmental disabilities.
3112	(d)  Qualified Medicare beneficiaries.
3113	(e)  Adults who have chronic, high-cost medical conditions.
3114	(f)  Adults and children who have mental health problems.
3115	(g)  Other recipients for whom managed care plans and
3116	MediPass offer the opportunity of more cost-effective care and
3117	greater access to qualified providers.
3118	(8)(a)  The agency shall encourage the development of
3119	public and private partnerships to foster the growth of health
3120	maintenance organizations and prepaid health plans that will
3121	provide high-quality health care to Medicaid recipients.
3122	(b)  Subject to the availability of moneys and any
3123	limitations established by the General Appropriations Act or
3124	chapter 216, the agency is authorized to enter into contracts
3125	with traditional providers of health care to low-income persons
3126	to assist such providers with the technical aspects of
3127	cooperatively developing Medicaid prepaid health plans.
3128	1.  The agency may contract with disproportionate share
3129	hospitals, county health departments, federally initiated or
3130	federally funded community health centers, and counties that
3131	operate either a hospital or a community clinic.
3132	2.  A contract may not be for more than $100,000 per year,
3133	and no contract may be extended with any particular provider for
3134	more than 2 years. The contract is intended only as seed or
3135	development funding and requires a commitment from the
3136	interested party.
3137	3.  A contract must require participation by at least one
3138	community health clinic and one disproportionate share hospital.
3139	(7)(9)(a)  The agency shall develop and implement a
3140	comprehensive plan to ensure that recipients are adequately
3141	informed of their choices and rights under all Medicaid managed
3142	care programs and that Medicaid managed care programs meet
3143	acceptable standards of quality in patient care, patient
3144	satisfaction, and financial solvency.
3145	(b)  The agency shall provide adequate means for informing
3146	patients of their choice and rights under a managed care plan at
3147	the time of eligibility determination.
3148	(c)  The agency shall require managed care plans and
3149	MediPass providers to demonstrate and document plans and
3150	activities, as defined by rule, including outreach and followup,
3151	undertaken to ensure that Medicaid recipients receive the health
3152	care service to which they are entitled.
3153
3154	This subsection expires October 1, 2014.
3155	(8)(10)  The agency shall consult with Medicaid consumers
3156	and their representatives on an ongoing basis regarding
3157	measurements of patient satisfaction, procedures for resolving
3158	patient grievances, standards for ensuring quality of care,
3159	mechanisms for providing patient access to services, and
3160	policies affecting patient care. This subsection expires October
3161	1, 2014.
3162	(9)(11)  The agency may extend eligibility for Medicaid
3163	recipients enrolled in licensed and accredited health
3164	maintenance organizations for the duration of the enrollment
3165	period or for 6 months, whichever is earlier, provided the
3166	agency certifies that such an offer will not increase state
3167	expenditures. This subsection expires October 1, 2013.
3168	(10)(12)  A managed care plan that has a Medicaid contract
3169	shall at least annually review each primary care physician's
3170	active patient load and shall ensure that additional Medicaid
3171	recipients are not assigned to physicians who have a total
3172	active patient load of more than 3,000 patients. As used in this
3173	subsection, the term "active patient" means a patient who is
3174	seen by the same primary care physician, or by a physician
3175	assistant or advanced registered nurse practitioner under the
3176	supervision of the primary care physician, at least three times
3177	within a calendar year. Each primary care physician shall
3178	annually certify to the managed care plan whether or not his or
3179	her patient load exceeds the limits established under this
3180	subsection and the managed care plan shall accept such
3181	certification on face value as compliance with this subsection.
3182	The agency shall accept the managed care plan's representations
3183	that it is in compliance with this subsection based on the
3184	certification of its primary care physicians, unless the agency
3185	has an objective indication that access to primary care is being
3186	compromised, such as receiving complaints or grievances relating
3187	to access to care. If the agency determines that an objective
3188	indication exists that access to primary care is being
3189	compromised, it may verify the patient load certifications
3190	submitted by the managed care plan's primary care physicians and
3191	that the managed care plan is not assigning Medicaid recipients
3192	to primary care physicians who have an active patient load of
3193	more than 3,000 patients. This subsection expires October 1,
3194	2014.
3195	(11)(13)  Effective July 1, 2003, the agency shall adjust
3196	the enrollee assignment process of Medicaid managed prepaid
3197	health plans for those Medicaid managed prepaid plans operating
3198	in Miami-Dade County which have executed a contract with the
3199	agency for a minimum of 8 consecutive years in order for the
3200	Medicaid managed prepaid plan to maintain a minimum enrollment
3201	level of 15,000 members per month. When assigning enrollees
3202	pursuant to this subsection, the agency shall give priority to
3203	providers that initially qualified under this subsection until
3204	such providers reach and maintain an enrollment level of 15,000
3205	members per month. A prepaid health plan that has a statewide
3206	Medicaid enrollment of 25,000 or more members is not eligible
3207	for enrollee assignments under this subsection. This subsection
3208	expires October 1, 2014.
3209	(12)(14)  The agency shall include in its calculation of
3210	the hospital inpatient component of a Medicaid health
3211	maintenance organization's capitation rate any special payments,
3212	including, but not limited to, upper payment limit or
3213	disproportionate share hospital payments, made to qualifying
3214	hospitals through the fee-for-service program. The agency may
3215	seek federal waiver approval or state plan amendment as needed
3216	to implement this adjustment.
3217	(13)  The agency shall develop a process to enable any
3218	recipient with access to employer-sponsored health care coverage
3219	to opt out of all eligible plans in the Medicaid program and to
3220	use Medicaid financial assistance to pay for the recipient's
3221	share of cost in any such employer-sponsored coverage.
3222	Contingent on federal approval, the agency shall also enable
3223	recipients with access to other insurance or related products
3224	that provide access to health care services created pursuant to
3225	state law, including any plan or product available pursuant to
3226	the Florida Health Choices Program or any health exchange, to
3227	opt out. The amount of financial assistance provided for each
3228	recipient may not exceed the amount of the Medicaid premium that
3229	would have been paid to a plan for that recipient.
3230	(14)  The agency shall maintain and operate the Medicaid
3231	Encounter Data System to collect, process, store, and report on
3232	covered services provided to all Florida Medicaid recipients
3233	enrolled in prepaid managed care plans.
3234	(a)  Prepaid managed care plans shall submit encounter data
3235	electronically in a format that complies with the Health
3236	Insurance Portability and Accountability Act provisions for
3237	electronic claims and in accordance with deadlines established
3238	by the agency. Prepaid managed care plans must certify that the
3239	data reported is accurate and complete.
3240	(b)  The agency is responsible for validating the data
3241	submitted by the plans. The agency shall develop methods and
3242	protocols for ongoing analysis of the encounter data that
3243	adjusts for differences in characteristics of prepaid plan
3244	enrollees to allow comparison of service utilization among plans
3245	and against expected levels of use. The analysis shall be used
3246	to identify possible cases of systemic underutilization or
3247	denials of claims and inappropriate service utilization such as
3248	higher-than-expected emergency department encounters. The
3249	analysis shall provide periodic feedback to the plans and enable
3250	the agency to establish corrective action plans when necessary.
3251	One of the focus areas for the analysis shall be the use of
3252	prescription drugs.
3253	(15)  The agency may establish a per-member, per-month
3254	payment for Medicare Advantage Special Needs members that are
3255	also eligible for Medicaid as a mechanism for meeting the
3256	state's cost-sharing obligation. The agency may also develop a
3257	per-member, per-month payment only for Medicaid-covered services
3258	for which the state is responsible. The agency shall develop a
3259	mechanism to ensure that such per-member, per-month payment
3260	enhances the value to the state and enrolled members by limiting
3261	cost sharing, enhances the scope of Medicare supplemental
3262	benefits that are equal to or greater than Medicaid coverage for
3263	select services, and improves care coordination.
3264	(16)  The agency shall establish, and managed care plans
3265	shall use, a uniform method of accounting for and reporting
3266	medical and nonmedical costs. The agency shall make such
3267	information available to the public.
3268	(17)  The agency may, on a case-by-case basis, exempt a
3269	recipient from mandatory enrollment in a managed care plan when
3270	the recipient has a unique, time-limited disease or condition-
3271	related circumstance and managed care enrollment will interfere
3272	with ongoing care because the recipient's provider does not
3273	participate in the managed care plans available in the
3274	recipient's area.
3275	(18)  The agency shall contract with a single provider
3276	service network to function as a third-party administrator and
3277	managing entity for the MediPass program in all counties with
3278	fewer than two prepaid plans. The contractor may earn an
3279	administrative fee, if the fee is less than any savings
3280	determined by the reconciliation process pursuant to s.
3281	409.912(4)(d)1. This subsection expires October 1, 2014, or upon
3282	full implementation of the managed medical assistance program,
3283	whichever is sooner.
3284	(19)  Subject to federal approval, the agency shall
3285	contract with a single provider service network to function as a
3286	third-party administrator and managing entity for the Medically
3287	Needy program in all counties. The contractor shall provide care
3288	coordination and utilization management in order to achieve more
3289	cost-effective services for Medically Needy enrollees. To
3290	facilitate the care management functions of the provider service
3291	network, enrollment in the network shall be for a continuous 6-
3292	month period or until the end of the contract between the
3293	provider service network and the agency, whichever is sooner.
3294	Beginning the second month after the determination of
3295	eligibility, the contractor may collect a monthly premium from
3296	each Medically Needy recipient provided the premium does not
3297	exceed the enrollee's share of cost as determined by the
3298	Department of Children and Family Services. The contractor must
3299	provide a 90-day grace period before disenrolling a Medically
3300	Needy recipient for failure to pay premiums. The contractor may
3301	earn an administrative fee, if the fee is less than any savings
3302	determined by the reconciliation process pursuant to s.
3303	409.912(4)(d)1. Premium revenue collected from the recipients
3304	shall be deducted from the contractor's earned savings. This
3305	subsection expires October 1, 2014, or upon full implementation
3306	of the managed medical assistance program, whichever is sooner.
3307	Section 18.  Subsection (15) of section 430.04, Florida
3308	Statutes, is amended to read:
3309	430.04  Duties and responsibilities of the Department of
3310	Elderly Affairs.-The Department of Elderly Affairs shall:
3311	(15)  Administer all Medicaid waivers and programs relating
3312	to elders and their appropriations. The waivers include, but are
3313	not limited to:
3314	(a)  The Alzheimer's Dementia-Specific Medicaid Waiver as
3315	established in s. 430.502(7), (8), and (9).
3316	(a)(b)  The Assisted Living for the Frail Elderly Waiver.
3317	(b)(c)  The Aged and Disabled Adult Waiver.
3318	(c)(d)  The Adult Day Health Care Waiver.
3319	(d)(e)  The Consumer-Directed Care Plus Program as defined
3320	in s. 409.221.
3321	(e)(f)  The Program of All-inclusive Care for the Elderly.
3322	(f)(g)  The Long-Term Care Community-Based Diversion Pilot
3323	Project as described in s. 430.705.
3324	(g)(h)  The Channeling Services Waiver for Frail Elders.
3325
3326	The department shall develop a transition plan for recipients
3327	receiving services in long-term care Medicaid waivers for elders
3328	or disabled adults on the date eligible plans become available
3329	in each recipient's region defined in s. 409.981(2) to enroll
3330	those recipients in eligible plans. This subsection expires
3331	October 1, 2014.
3332	Section 19.  Section 430.2053, Florida Statutes, is amended
3333	to read:
3334	430.2053  Aging resource centers.-
3335	(1)  The department, in consultation with the Agency for
3336	Health Care Administration and the Department of Children and
3337	Family Services, shall develop pilot projects for aging resource
3338	centers. By October 31, 2004, the department, in consultation
3339	with the agency and the Department of Children and Family
3340	Services, shall develop an implementation plan for aging
3341	resource centers and submit the plan to the Governor, the
3342	President of the Senate, and the Speaker of the House of
3343	Representatives. The plan must include qualifications for
3344	designation as a center, the functions to be performed by each
3345	center, and a process for determining that a current area agency
3346	on aging is ready to assume the functions of an aging resource
3347	center.
3348	(2)  Each area agency on aging shall develop, in
3349	consultation with the existing community care for the elderly
3350	lead agencies within their planning and service areas, a
3351	proposal that describes the process the area agency on aging
3352	intends to undertake to transition to an aging resource center
3353	prior to July 1, 2005, and that describes the area agency's
3354	compliance with the requirements of this section. The proposals
3355	must be submitted to the department prior to December 31, 2004.
3356	The department shall evaluate all proposals for readiness and,
3357	prior to March 1, 2005, shall select three area agencies on
3358	aging which meet the requirements of this section to begin the
3359	transition to aging resource centers. Those area agencies on
3360	aging which are not selected to begin the transition to aging
3361	resource centers shall, in consultation with the department and
3362	the existing community care for the elderly lead agencies within
3363	their planning and service areas, amend their proposals as
3364	necessary and resubmit them to the department prior to July 1,
3365	2005. The department may transition additional area agencies to
3366	aging resource centers as it determines that area agencies are
3367	in compliance with the requirements of this section.
3368	(3)  The Auditor General and the Office of Program Policy
3369	Analysis and Government Accountability (OPPAGA) shall jointly
3370	review and assess the department's process for determining an
3371	area agency's readiness to transition to an aging resource
3372	center.
3373	(a)  The review must, at a minimum, address the
3374	appropriateness of the department's criteria for selection of an
3375	area agency to transition to an aging resource center, the
3376	instruments applied, the degree to which the department
3377	accurately determined each area agency's compliance with the
3378	readiness criteria, the quality of the technical assistance
3379	provided by the department to an area agency in correcting any
3380	weaknesses identified in the readiness assessment, and the
3381	degree to which each area agency overcame any identified
3382	weaknesses.
3383	(b)  Reports of these reviews must be submitted to the
3384	appropriate substantive and appropriations committees in the
3385	Senate and the House of Representatives on March 1 and September
3386	1 of each year until full transition to aging resource centers
3387	has been accomplished statewide, except that the first report
3388	must be submitted by February 1, 2005, and must address all
3389	readiness activities undertaken through December 31, 2004. The
3390	perspectives of all participants in this review process must be
3391	included in each report.
3392	(2)(4)  The purposes of an aging resource center shall be:
3393	(a)  To provide Florida's elders and their families with a
3394	locally focused, coordinated approach to integrating information
3395	and referral for all available services for elders with the
3396	eligibility determination entities for state and federally
3397	funded long-term-care services.
3398	(b)  To provide for easier access to long-term-care
3399	services by Florida's elders and their families by creating
3400	multiple access points to the long-term-care network that flow
3401	through one established entity with wide community recognition.
3402	(3)(5)  The duties of an aging resource center are to:
3403	(a)  Develop referral agreements with local community
3404	service organizations, such as senior centers, existing elder
3405	service providers, volunteer associations, and other similar
3406	organizations, to better assist clients who do not need or do
3407	not wish to enroll in programs funded by the department or the
3408	agency. The referral agreements must also include a protocol,
3409	developed and approved by the department, which provides
3410	specific actions that an aging resource center and local
3411	community service organizations must take when an elder or an
3412	elder's representative seeking information on long-term-care
3413	services contacts a local community service organization prior
3414	to contacting the aging resource center. The protocol shall be
3415	designed to ensure that elders and their families are able to
3416	access information and services in the most efficient and least
3417	cumbersome manner possible.
3418	(b)  Provide an initial screening of all clients who
3419	request long-term-care services to determine whether the person
3420	would be most appropriately served through any combination of
3421	federally funded programs, state-funded programs, locally funded
3422	or community volunteer programs, or private funding for
3423	services.
3424	(c)  Determine eligibility for the programs and services
3425	listed in subsection (9) (11) for persons residing within the
3426	geographic area served by the aging resource center and
3427	determine a priority ranking for services which is based upon
3428	the potential recipient's frailty level and likelihood of
3429	institutional placement without such services.
3430	(d)  Manage the availability of financial resources for the
3431	programs and services listed in subsection (9) (11) for persons
3432	residing within the geographic area served by the aging resource
3433	center.
3434	(e)  When financial resources become available, refer a
3435	client to the most appropriate entity to begin receiving
3436	services. The aging resource center shall make referrals to lead
3437	agencies for service provision that ensure that individuals who
3438	are vulnerable adults in need of services pursuant to s.
3439	415.104(3)(b), or who are victims of abuse, neglect, or
3440	exploitation in need of immediate services to prevent further
3441	harm and are referred by the adult protective services program,
3442	are given primary consideration for receiving community-care-
3443	for-the-elderly services in compliance with the requirements of
3444	s. 430.205(5)(a) and that other referrals for services are in
3445	compliance with s. 430.205(5)(b).
3446	(f)  Convene a work group to advise in the planning,
3447	implementation, and evaluation of the aging resource center. The
3448	work group shall be comprised of representatives of local
3449	service providers, Alzheimer's Association chapters, housing
3450	authorities, social service organizations, advocacy groups,
3451	representatives of clients receiving services through the aging
3452	resource center, and any other persons or groups as determined
3453	by the department. The aging resource center, in consultation
3454	with the work group, must develop annual program improvement
3455	plans that shall be submitted to the department for
3456	consideration. The department shall review each annual
3457	improvement plan and make recommendations on how to implement
3458	the components of the plan.
3459	(g)  Enhance the existing area agency on aging in each
3460	planning and service area by integrating, either physically or
3461	virtually, the staff and services of the area agency on aging
3462	with the staff of the department's local CARES Medicaid nursing
3463	home preadmission screening unit and a sufficient number of
3464	staff from the Department of Children and Family Services'
3465	Economic Self-Sufficiency Unit necessary to determine the
3466	financial eligibility for all persons age 60 and older residing
3467	within the area served by the aging resource center that are
3468	seeking Medicaid services, Supplemental Security Income, and
3469	food assistance.
3470	(h)  Assist clients who request long-term care services in
3471	being evaluated for eligibility for enrollment in the Medicaid
3472	long-term care managed care program as eligible plans become
3473	available in each of the regions pursuant to s. 409.981(2).
3474	(i)  Provide choice counseling for the Medicaid long-term
3475	care managed care program by integrating, either physically or
3476	virtually, choice counseling staff and services as eligible
3477	plans become available in each of the regions pursuant to s.
3478	409.981(2). Pursuant to s. 409.984(1), the agency may contract
3479	directly with the aging resource center to provide choice
3480	counseling services or may contract with another vendor if the
3481	aging resource center does not choose to provide such services.
3482	(j)  Assist Medicaid recipients enrolled in the Medicaid
3483	long-term care managed care program with informally resolving
3484	grievances with a managed care network and assist Medicaid
3485	recipients in accessing the managed care network's formal
3486	grievance process as eligible plans become available in each of
3487	the regions defined in s. 409.981(2).
3488	(4)(6)  The department shall select the entities to become
3489	aging resource centers based on each entity's readiness and
3490	ability to perform the duties listed in subsection (3) (5) and
3491	the entity's:
3492	(a)  Expertise in the needs of each target population the
3493	center proposes to serve and a thorough knowledge of the
3494	providers that serve these populations.
3495	(b)  Strong connections to service providers, volunteer
3496	agencies, and community institutions.
3497	(c)  Expertise in information and referral activities.
3498	(d)  Knowledge of long-term-care resources, including
3499	resources designed to provide services in the least restrictive
3500	setting.
3501	(e)  Financial solvency and stability.
3502	(f)  Ability to collect, monitor, and analyze data in a
3503	timely and accurate manner, along with systems that meet the
3504	department's standards.
3505	(g)  Commitment to adequate staffing by qualified personnel
3506	to effectively perform all functions.
3507	(h)  Ability to meet all performance standards established
3508	by the department.
3509	(5)(7)  The aging resource center shall have a governing
3510	body which shall be the same entity described in s. 20.41(7),
3511	and an executive director who may be the same person as
3512	described in s. 20.41(7). The governing body shall annually
3513	evaluate the performance of the executive director.
3514	(6)(8)  The aging resource center may not be a provider of
3515	direct services other than choice counseling as eligible plans
3516	become available in each of the regions defined in s.
3517	409.981(2), information and referral services, and screening.
3518	(7)(9)  The aging resource center must agree to allow the
3519	department to review any financial information the department
3520	determines is necessary for monitoring or reporting purposes,
3521	including financial relationships.
3522	(8)(10)  The duties and responsibilities of the community
3523	care for the elderly lead agencies within each area served by an
3524	aging resource center shall be to:
3525	(a)  Develop strong community partnerships to maximize the
3526	use of community resources for the purpose of assisting elders
3527	to remain in their community settings for as long as it is
3528	safely possible.
3529	(b)  Conduct comprehensive assessments of clients that have
3530	been determined eligible and develop a care plan consistent with
3531	established protocols that ensures that the unique needs of each
3532	client are met.
3533	(9)(11)  The services to be administered through the aging
3534	resource center shall include those funded by the following
3535	programs:
3536	(a)  Community care for the elderly.
3537	(b)  Home care for the elderly.
3538	(c)  Contracted services.
3539	(d)  Alzheimer's disease initiative.
3540	(e)  Aged and disabled adult Medicaid waiver. This
3541	paragraph expires October 1, 2013.
3542	(f)  Assisted living for the frail elderly Medicaid waiver.
3543	This paragraph expires October 1, 2013.
3544	(g)  Older Americans Act.
3545	(10)(12)  The department shall, prior to designation of an
3546	aging resource center, develop by rule operational and quality
3547	assurance standards and outcome measures to ensure that clients
3548	receiving services through all long-term-care programs
3549	administered through an aging resource center are receiving the
3550	appropriate care they require and that contractors and
3551	subcontractors are adhering to the terms of their contracts and
3552	are acting in the best interests of the clients they are
3553	serving, consistent with the intent of the Legislature to reduce
3554	the use of and cost of nursing home care. The department shall
3555	by rule provide operating procedures for aging resource centers,
3556	which shall include:
3557	(a)  Minimum standards for financial operation, including
3558	audit procedures.
3559	(b)  Procedures for monitoring and sanctioning of service
3560	providers.
3561	(c)  Minimum standards for technology utilized by the aging
3562	resource center.
3563	(d)  Minimum staff requirements which shall ensure that the
3564	aging resource center employs sufficient quality and quantity of
3565	staff to adequately meet the needs of the elders residing within
3566	the area served by the aging resource center.
3567	(e)  Minimum accessibility standards, including hours of
3568	operation.
3569	(f)  Minimum oversight standards for the governing body of
3570	the aging resource center to ensure its continuous involvement
3571	in, and accountability for, all matters related to the
3572	development, implementation, staffing, administration, and
3573	operations of the aging resource center.
3574	(g)  Minimum education and experience requirements for
3575	executive directors and other executive staff positions of aging
3576	resource centers.
3577	(h)  Minimum requirements regarding any executive staff
3578	positions that the aging resource center must employ and minimum
3579	requirements that a candidate must meet in order to be eligible
3580	for appointment to such positions.
3581	(11)(13)  In an area in which the department has designated
3582	an area agency on aging as an aging resource center, the
3583	department and the agency shall not make payments for the
3584	services listed in subsection (9) (11) and the Long-Term Care
3585	Community Diversion Project for such persons who were not
3586	screened and enrolled through the aging resource center. The
3587	department shall cease making payments for recipients in
3588	eligible plans as eligible plans become available in each of the
3589	regions defined in s. 409.981(2).
3590	(12)(14)  Each aging resource center shall enter into a
3591	memorandum of understanding with the department for
3592	collaboration with the CARES unit staff. The memorandum of
3593	understanding shall outline the staff person responsible for
3594	each function and shall provide the staffing levels necessary to
3595	carry out the functions of the aging resource center.
3596	(13)(15)  Each aging resource center shall enter into a
3597	memorandum of understanding with the Department of Children and
3598	Family Services for collaboration with the Economic Self-
3599	Sufficiency Unit staff. The memorandum of understanding shall
3600	outline which staff persons are responsible for which functions
3601	and shall provide the staffing levels necessary to carry out the
3602	functions of the aging resource center.
3603	(14)  As eligible plans become available in each of the
3604	regions defined in s. 409.981(2), if an aging resource center
3605	does not contract with the agency to provide Medicaid long-term
3606	care managed care choice counseling pursuant to s. 409.984(1),
3607	the aging resource center shall enter into a memorandum of
3608	understanding with the agency to coordinate staffing and
3609	collaborate with the choice counseling vendor. The memorandum of
3610	understanding shall identify the staff responsible for each
3611	function and shall provide the staffing levels necessary to
3612	carry out the functions of the aging resource center.
3613	(15)(16)  If any of the state activities described in this
3614	section are outsourced, either in part or in whole, the contract
3615	executing the outsourcing shall mandate that the contractor or
3616	its subcontractors shall, either physically or virtually,
3617	execute the provisions of the memorandum of understanding
3618	instead of the state entity whose function the contractor or
3619	subcontractor now performs.
3620	(16)(17)  In order to be eligible to begin transitioning to
3621	an aging resource center, an area agency on aging board must
3622	ensure that the area agency on aging which it oversees meets all
3623	of the minimum requirements set by law and in rule.
3624	(18)  The department shall monitor the three initial
3625	projects for aging resource centers and report on the progress
3626	of those projects to the Governor, the President of the Senate,
3627	and the Speaker of the House of Representatives by June 30,
3628	2005. The report must include an evaluation of the
3629	implementation process.
3630	(17)(19)(a)  Once an aging resource center is operational,
3631	the department, in consultation with the agency, may develop
3632	capitation rates for any of the programs administered through
3633	the aging resource center. Capitation rates for programs shall
3634	be based on the historical cost experience of the state in
3635	providing those same services to the population age 60 or older
3636	residing within each area served by an aging resource center.
3637	Each capitated rate may vary by geographic area as determined by
3638	the department.
3639	(b)  The department and the agency may determine for each
3640	area served by an aging resource center whether it is
3641	appropriate, consistent with federal and state laws and
3642	regulations, to develop and pay separate capitated rates for
3643	each program administered through the aging resource center or
3644	to develop and pay capitated rates for service packages which
3645	include more than one program or service administered through
3646	the aging resource center.
3647	(c)  Once capitation rates have been developed and
3648	certified as actuarially sound, the department and the agency
3649	may pay service providers the capitated rates for services when
3650	appropriate.
3651	(d)  The department, in consultation with the agency, shall
3652	annually reevaluate and recertify the capitation rates,
3653	adjusting forward to account for inflation, programmatic
3654	changes.
3655	(20)  The department, in consultation with the agency,
3656	shall submit to the Governor, the President of the Senate, and
3657	the Speaker of the House of Representatives, by December 1,
3658	2006, a report addressing the feasibility of administering the
3659	following services through aging resource centers beginning July
3660	1, 2007:
3661	(a)  Medicaid nursing home services.
3662	(b)  Medicaid transportation services.
3663	(c)  Medicaid hospice care services.
3664	(d)  Medicaid intermediate care services.
3665	(e)  Medicaid prescribed drug services.
3666	(f)  Medicaid assistive care services.
3667	(g)  Any other long-term-care program or Medicaid service.
3668	(18)(21)  This section shall not be construed to allow an
3669	aging resource center to restrict, manage, or impede the local
3670	fundraising activities of service providers.
3671	Section 20.  Effective October 1, 2013, sections 430.701,
3672	430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3673	430.708, and 430.709, Florida Statutes, are repealed.
3674	Section 21.  Sections 409.9301, 409.942, 409.944, 409.945,
3675	409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3676	as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3677	402.87, Florida Statutes, respectively.
3678	Section 22.  Paragraph (a) of subsection (1) of section
3679	443.111, Florida Statutes, is amended to read:
3680	443.111  Payment of benefits.-
3681	(1)  MANNER OF PAYMENT.-Benefits are payable from the fund
3682	in accordance with rules adopted by the Agency for Workforce
3683	Innovation, subject to the following requirements:
3684	(a)  Benefits are payable by mail or electronically.
3685	Notwithstanding s. 402.84(4) s. 409.942(4), the agency may
3686	develop a system for the payment of benefits by electronic funds
3687	transfer, including, but not limited to, debit cards, electronic
3688	payment cards, or any other means of electronic payment that the
3689	agency deems to be commercially viable or cost-effective.
3690	Commodities or services related to the development of such a
3691	system shall be procured by competitive solicitation, unless
3692	they are purchased from a state term contract pursuant to s.
3693	287.056. The agency shall adopt rules necessary to administer
3694	the system.
3695	Section 23.  Subsection (4) of section 641.386, Florida
3696	Statutes, is amended to read:
3697	641.386  Agent licensing and appointment required;
3698	exceptions.-
3699	(4)  All agents and health maintenance organizations shall
3700	comply with and be subject to the applicable provisions of ss.
3701	641.309 and 409.912(20)(21), and all companies and entities
3702	appointing agents shall comply with s. 626.451, when marketing
3703	for any health maintenance organization licensed pursuant to
3704	this part, including those organizations under contract with the
3705	Agency for Health Care Administration to provide health care
3706	services to Medicaid recipients or any private entity providing
3707	health care services to Medicaid recipients pursuant to a
3708	prepaid health plan contract with the Agency for Health Care
3709	Administration.
3710	Section 24.  Subsections (6) and (7) of section 766.118,
3711	Florida Statutes, are renumbered as subsections (7) and (8),
3712	respectively, and a new subsection (6) is added to that section,
3713	to read:
3714	766.118  Determination of noneconomic damages.-
3715	(6)  LIMITATION ON NONECONOMIC DAMAGES FOR NEGLIGENCE OF
3716	PRACTITIONERS PROVIDING SERVICES AND CARE TO MEDICAID
3717	RECIPIENTS.-Notwithstanding subsections (2), (3), (4), and (5),
3718	with respect to a cause of action for personal injury or
3719	wrongful death arising from medical negligence of practitioners
3720	providing services and care to Medicaid recipients as defined in
3721	s. 409.901, regardless of the number of such practitioner
3722	defendants providing services and care to Medicaid recipients as
3723	defined in s. 409.901, noneconomic damages may not exceed
3724	$300,000 per claimant. A practitioner providing services and
3725	care to Medicaid recipients as defined in s. 409.901 is not
3726	liable for more than $200,000 in noneconomic damages, regardless
3727	of the number of claimants.
3728	Section 25.  The Agency for Health Care Administration
3729	shall develop a plan for implementing s. 409.975(8), Florida
3730	Statutes, and shall immediately seek federal approval to
3731	implement that subsection. The plan shall include a preliminary
3732	calculation of actuarially sound rates and estimated fiscal
3733	impact.
3734	Section 26.  Except as otherwise expressly provided in this
3735	act, this act shall take effect July 1, 2011, if HB 7107 or
3736	similar legislation is adopted in the same legislative session
3737	or an extension thereof and becomes law.

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