Florida Senate - 2013 CONFERENCE COMMITTEE AMENDMENT
Bill No. SB 1520
Barcode 214070
LEGISLATIVE ACTION
Senate . House
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Floor: AD/CR .
05/03/2013 11:52 AM .
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The Conference Committee on SB 1520 recommended the following:
1 Senate Conference Committee Amendment (with title
2 amendment)
3
4 Delete everything after the enacting clause
5 and insert:
6 Section 1. Section 381.0403, Florida Statutes, is repealed.
7 Section 2. Paragraph (e) of subsection (2) of section
8 395.602, Florida Statutes, is amended to read:
9 395.602 Rural hospitals.—
10 (2) DEFINITIONS.—As used in this part:
11 (e) “Rural hospital” means an acute care hospital licensed
12 under this chapter, having 100 or fewer licensed beds and an
13 emergency room, which is:
14 1. The sole provider within a county with a population
15 density of no greater than 100 persons per square mile;
16 2. An acute care hospital, in a county with a population
17 density of no greater than 100 persons per square mile, which is
18 at least 30 minutes of travel time, on normally traveled roads
19 under normal traffic conditions, from any other acute care
20 hospital within the same county;
21 3. A hospital supported by a tax district or subdistrict
22 whose boundaries encompass a population of 100 persons or fewer
23 per square mile;
24 4. A hospital in a constitutional charter county with a
25 population of over 1 million persons that has imposed a local
26 option health service tax pursuant to law and in an area that
27 was directly impacted by a catastrophic event on August 24,
28 1992, for which the Governor of Florida declared a state of
29 emergency pursuant to chapter 125, and has 120 beds or less that
30 serves an agricultural community with an emergency room
31 utilization of no less than 20,000 visits and a Medicaid
32 inpatient utilization rate greater than 15 percent;
33 5. A hospital with a service area that has a population of
34 100 persons or fewer per square mile. As used in this
35 subparagraph, the term “service area” means the fewest number of
36 zip codes that account for 75 percent of the hospital’s
37 discharges for the most recent 5-year period, based on
38 information available from the hospital inpatient discharge
39 database in the Florida Center for Health Information and Policy
40 Analysis at the agency for Health Care Administration; or
41 6. A hospital designated as a critical access hospital, as
42 defined in s. 408.07(15).
43
44 Population densities used in this paragraph must be based upon
45 the most recently completed United States census. A hospital
46 that received funds under s. 409.9116 for a quarter beginning no
47 later than July 1, 2002, is deemed to have been and shall
48 continue to be a rural hospital from that date through June 30,
49 2015, if the hospital continues to have 100 or fewer licensed
50 beds and an emergency room, or meets the criteria of
51 subparagraph 4. An acute care hospital that has not previously
52 been designated as a rural hospital and that meets the criteria
53 of this paragraph shall be granted such designation upon
54 application, including supporting documentation, to the agency
55 for Health Care Administration. A hospital that was licensed as
56 a rural hospital during the 2010-2011 or 2011-2012 fiscal year
57 shall continue to be a rural hospital from the date of
58 designation through June 30, 2015, if the hospital continues to
59 have 100 or fewer licensed beds and an emergency room.
60 Section 3. Paragraphs (c), (d), and (f) of subsection (5)
61 and subsection (6) of section 409.905, Florida Statutes, are
62 amended to read:
63 409.905 Mandatory Medicaid services.—The agency may make
64 payments for the following services, which are required of the
65 state by Title XIX of the Social Security Act, furnished by
66 Medicaid providers to recipients who are determined to be
67 eligible on the dates on which the services were provided. Any
68 service under this section shall be provided only when medically
69 necessary and in accordance with state and federal law.
70 Mandatory services rendered by providers in mobile units to
71 Medicaid recipients may be restricted by the agency. Nothing in
72 this section shall be construed to prevent or limit the agency
73 from adjusting fees, reimbursement rates, lengths of stay,
74 number of visits, number of services, or any other adjustments
75 necessary to comply with the availability of moneys and any
76 limitations or directions provided for in the General
77 Appropriations Act or chapter 216.
78 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
79 all covered services provided for the medical care and treatment
80 of a recipient who is admitted as an inpatient by a licensed
81 physician or dentist to a hospital licensed under part I of
82 chapter 395. However, the agency shall limit the payment for
83 inpatient hospital services for a Medicaid recipient 21 years of
84 age or older to 45 days or the number of days necessary to
85 comply with the General Appropriations Act. Effective August 1,
86 2012, the agency shall limit payment for hospital emergency
87 department visits for a nonpregnant Medicaid recipient 21 years
88 of age or older to six visits per fiscal year.
89 (c) The agency shall implement a prospective payment
90 methodology for establishing base reimbursement rates for
91 inpatient hospital services each hospital based on allowable
92 costs, as defined by the agency. Rates shall be calculated
93 annually and take effect July 1 of each year based on the most
94 recent complete and accurate cost report submitted by each
95 hospital. The methodology shall categorize each inpatient
96 admission into a diagnosis-related group and assign a relative
97 payment weight to the base rate according to the average
98 relative amount of hospital resources used to treat a patient in
99 a specific diagnosis-related group category. The agency may
100 adopt the most recent relative weights calculated and made
101 available by the Nationwide Inpatient Sample maintained by the
102 Agency for Healthcare Research and Quality or may adopt
103 alternative weights if the agency finds that Florida-specific
104 weights deviate with statistical significance from national
105 weights for high-volume diagnosis-related groups. The agency
106 shall establish a single, uniform base rate for all hospitals
107 unless specifically exempt pursuant to s. 409.908(1).
108 1. Adjustments may not be made to the rates after October
109 31 of the state fiscal year in which the rates take effect,
110 except for cases of insufficient collections of
111 intergovernmental transfers authorized under s. 409.908(1) or
112 the General Appropriations Act. In such cases, the agency shall
113 submit a budget amendment or amendments under chapter 216
114 requesting approval of rate reductions by amounts necessary for
115 the aggregate reduction to equal the dollar amount of
116 intergovernmental transfers not collected and the corresponding
117 federal match. Notwithstanding the $1 million limitation on
118 increases to an approved operating budget contained in ss.
119 216.181(11) and 216.292(3), a budget amendment exceeding that
120 dollar amount is subject to notice and objection procedures set
121 forth in s. 216.177.
122 2. Errors in source data or calculations cost reporting or
123 calculation of rates discovered after October 31 must be
124 reconciled in a subsequent rate period. However, the agency may
125 not make any adjustment to a hospital’s reimbursement rate more
126 than 5 years after a hospital is notified of an audited rate
127 established by the agency. The prohibition against adjustments
128 requirement that the agency may not make any adjustment to a
129 hospital’s reimbursement rate more than 5 years after
130 notification a hospital is notified of an audited rate
131 established by the agency is remedial and applies to actions by
132 providers involving Medicaid claims for hospital services.
133 Hospital reimbursement is rates are subject to such limits or
134 ceilings as may be established in law or described in the
135 agency’s hospital reimbursement plan. Specific exemptions to the
136 limits or ceilings may be provided in the General Appropriations
137 Act.
138 (d) The agency shall implement a comprehensive utilization
139 management program for hospital neonatal intensive care stays in
140 certain high-volume participating hospitals, select counties, or
141 statewide, and replace existing hospital inpatient utilization
142 management programs for neonatal intensive care admissions. The
143 program shall be designed to manage appropriate admissions and
144 discharges the lengths of stay for children being treated in
145 neonatal intensive care units and must seek the earliest
146 medically appropriate discharge to the child’s home or other
147 less costly treatment setting. The agency may competitively bid
148 a contract for the selection of a qualified organization to
149 provide neonatal intensive care utilization management services.
150 The agency may seek federal waivers to implement this
151 initiative.
152 (f) The agency shall develop a plan to convert Medicaid
153 inpatient hospital rates to a prospective payment system that
154 categorizes each case into diagnosis-related groups (DRG) and
155 assigns a payment weight based on the average resources used to
156 treat Medicaid patients in that DRG. To the extent possible, the
157 agency shall propose an adaptation of an existing prospective
158 payment system, such as the one used by Medicare, and shall
159 propose such adjustments as are necessary for the Medicaid
160 population and to maintain budget neutrality for inpatient
161 hospital expenditures.
162 1. The plan must:
163 a. Define and describe DRGs for inpatient hospital care
164 specific to Medicaid in this state;
165 b. Determine the use of resources needed for each DRG;
166 c. Apply current statewide levels of funding to DRGs based
167 on the associated resource value of DRGs. Current statewide
168 funding levels shall be calculated both with and without the use
169 of intergovernmental transfers;
170 d. Calculate the current number of services provided in the
171 Medicaid program based on DRGs defined under this subparagraph;
172 e. Estimate the number of cases in each DRG for future
173 years based on agency data and the official workload estimates
174 of the Social Services Estimating Conference;
175 f. Calculate the expected total Medicaid payments in the
176 current year for each hospital with a Medicaid provider
177 agreement, based on the DRGs and estimated workload;
178 g. Propose supplemental DRG payments to augment hospital
179 reimbursements based on patient acuity and individual hospital
180 characteristics, including classification as a children’s
181 hospital, rural hospital, trauma center, burn unit, and other
182 characteristics that could warrant higher reimbursements, while
183 maintaining budget neutrality; and
184 h. Estimate potential funding for each hospital with a
185 Medicaid provider agreement for DRGs defined pursuant to this
186 subparagraph and supplemental DRG payments using current funding
187 levels, calculated both with and without the use of
188 intergovernmental transfers.
189 2. The agency shall engage a consultant with expertise and
190 experience in the implementation of DRG systems for hospital
191 reimbursement to develop the DRG plan under subparagraph 1.
192 3. The agency shall submit the DRG plan, identifying all
193 steps necessary for the transition and any costs associated with
194 plan implementation, to the Governor, the President of the
195 Senate, and the Speaker of the House of Representatives no later
196 than January 1, 2013. The plan shall include a timeline
197 necessary to complete full implementation by July 1, 2013. If,
198 during implementation of this paragraph, the agency determines
199 that these timeframes might not be achievable, the agency shall
200 report to the Legislative Budget Commission the status of its
201 implementation efforts, the reasons the timeframes might not be
202 achievable, and proposals for new timeframes.
203 (6) HOSPITAL OUTPATIENT SERVICES.—
204 (a) The agency shall pay for preventive, diagnostic,
205 therapeutic, or palliative care and other services provided to a
206 recipient in the outpatient portion of a hospital licensed under
207 part I of chapter 395, and provided under the direction of a
208 licensed physician or licensed dentist, except that payment for
209 such care and services is limited to $1,500 per state fiscal
210 year per recipient, unless an exception has been made by the
211 agency, and with the exception of a Medicaid recipient under age
212 21, in which case the only limitation is medical necessity.
213 (b) The agency shall implement a methodology for
214 establishing base reimbursement rates for outpatient services
215 for each hospital based on allowable costs, as defined by the
216 agency. Rates shall be calculated annually and take effect July
217 1 of each year based on the most recent complete and accurate
218 cost report submitted by each hospital.
219 1. Adjustments may not be made to the rates after October
220 31 of the state fiscal year in which the rates take effect,
221 except for cases of insufficient collections of
222 intergovernmental transfers authorized under s. 409.908(1) or
223 the General Appropriations Act. In such cases, the agency shall
224 submit a budget amendment or amendments under chapter 216
225 requesting approval of rate reductions by amounts necessary for
226 the aggregate reduction to equal the dollar amount of
227 intergovernmental transfers not collected and the corresponding
228 federal match. Notwithstanding the $1 million limitation on
229 increases to an approved operating budget under ss. 216.181(11)
230 and 216.292(3), a budget amendment exceeding that dollar amount
231 is subject to notice and objection procedures set forth in s.
232 216.177.
233 2. Errors in source data or calculations discovered after
234 October 31 must be reconciled in a subsequent rate period.
235 However, the agency may not make any adjustment to a hospital’s
236 reimbursement more than 5 years after a hospital is notified of
237 an audited rate established by the agency. The prohibition
238 against adjustments more than 5 years after notification is
239 remedial and applies to actions by providers involving Medicaid
240 claims for hospital services. Hospital reimbursement is subject
241 to such limits or ceilings as may be established in law or
242 described in the agency’s hospital reimbursement plan. Specific
243 exemptions to the limits or ceilings may be provided in the
244 General Appropriations Act.
245 Section 4. Paragraph (a) of subsection (1) and subsection
246 (23) of section 409.908, Florida Statutes, are amended to read:
247 409.908 Reimbursement of Medicaid providers.—Subject to
248 specific appropriations, the agency shall reimburse Medicaid
249 providers, in accordance with state and federal law, according
250 to methodologies set forth in the rules of the agency and in
251 policy manuals and handbooks incorporated by reference therein.
252 These methodologies may include fee schedules, reimbursement
253 methods based on cost reporting, negotiated fees, competitive
254 bidding pursuant to s. 287.057, and other mechanisms the agency
255 considers efficient and effective for purchasing services or
256 goods on behalf of recipients. If a provider is reimbursed based
257 on cost reporting and submits a cost report late and that cost
258 report would have been used to set a lower reimbursement rate
259 for a rate semester, then the provider’s rate for that semester
260 shall be retroactively calculated using the new cost report, and
261 full payment at the recalculated rate shall be effected
262 retroactively. Medicare-granted extensions for filing cost
263 reports, if applicable, shall also apply to Medicaid cost
264 reports. Payment for Medicaid compensable services made on
265 behalf of Medicaid eligible persons is subject to the
266 availability of moneys and any limitations or directions
267 provided for in the General Appropriations Act or chapter 216.
268 Further, nothing in this section shall be construed to prevent
269 or limit the agency from adjusting fees, reimbursement rates,
270 lengths of stay, number of visits, or number of services, or
271 making any other adjustments necessary to comply with the
272 availability of moneys and any limitations or directions
273 provided for in the General Appropriations Act, provided the
274 adjustment is consistent with legislative intent.
275 (1) Reimbursement to hospitals licensed under part I of
276 chapter 395 must be made prospectively or on the basis of
277 negotiation.
278 (a) Reimbursement for inpatient care is limited as provided
279 for in s. 409.905(5), except as otherwise provided in this
280 subsection. for:
281 1. If authorized by the General Appropriations Act, the
282 agency may modify reimbursement for specific types of services
283 or diagnoses, recipient ages, and hospital provider types The
284 raising of rate reimbursement caps, excluding rural hospitals.
285 2. The agency may establish an alternative methodology to
286 the DRG-based prospective payment system to set reimbursement
287 rates for:
288 a. State-owned psychiatric hospitals.
289 b. Newborn hearing screening services.
290 c. Transplant services for which the agency has established
291 a global fee.
292 d. Recipients who have tuberculosis that is resistant to
293 therapy who are in need of long-term, hospital-based treatment
294 pursuant to s. 392.62 Recognition of the costs of graduate
295 medical education.
296 3. The agency shall modify reimbursement according to other
297 methodologies recognized in the General Appropriations Act.
298
299 During the years funds are transferred from the Department of
300 Health, any reimbursement supported by such funds shall be
301 subject to certification by the Department of Health that the
302 hospital has complied with s. 381.0403. The agency may is
303 authorized to receive funds from state entities, including, but
304 not limited to, the Department of Health, local governments, and
305 other local political subdivisions, for the purpose of making
306 special exception payments, including federal matching funds,
307 through the Medicaid inpatient reimbursement methodologies.
308 Funds received from state entities or local governments for this
309 purpose shall be separately accounted for and may shall not be
310 commingled with other state or local funds in any manner. The
311 agency may certify all local governmental funds used as state
312 match under Title XIX of the Social Security Act, to the extent
313 and in the manner authorized under that the identified local
314 health care provider that is otherwise entitled to and is
315 contracted to receive such local funds is the benefactor under
316 the state’s Medicaid program as determined under the General
317 Appropriations Act and pursuant to an agreement between the
318 agency for Health Care Administration and the local governmental
319 entity. In order for the agency to certify such local
320 governmental funds, a local governmental entity must submit a
321 final, executed letter of agreement to the agency, which must be
322 received by October 1 of each fiscal year and provide the total
323 amount of local governmental funds authorized by the entity for
324 that fiscal year under this paragraph, paragraph (b), or the
325 General Appropriations Act. The local governmental entity shall
326 use a certification form prescribed by the agency. At a minimum,
327 the certification form must shall identify the amount being
328 certified and describe the relationship between the certifying
329 local governmental entity and the local health care provider.
330 The agency shall prepare an annual statement of impact which
331 documents the specific activities undertaken during the previous
332 fiscal year pursuant to this paragraph, to be submitted to the
333 Legislature annually by no later than January 1, annually.
334 (23)(a) The agency shall establish rates at a level that
335 ensures no increase in statewide expenditures resulting from a
336 change in unit costs effective July 1, 2011. Reimbursement rates
337 shall be as provided in the General Appropriations Act.
338 (b) Base rate reimbursement under a diagnosis-related group
339 payment methodology shall be provided in the General
340 Appropriations Act.
341 (c)(b) This subsection applies to the following provider
342 types:
343 1. Inpatient hospitals.
344 2. Outpatient hospitals.
345 3. Nursing homes.
346 4. County health departments.
347 5. Community intermediate care facilities for the
348 developmentally disabled.
349 6. Prepaid health plans.
350 (d)(c) The agency shall apply the effect of this subsection
351 to the reimbursement rates for nursing home diversion programs.
352 Section 5. Section 409.909, Florida Statutes, is created to
353 read:
354 409.909 Statewide Medicaid Residency Program.—
355 (1) The Statewide Medicaid Residency Program is established
356 to improve the quality of care and access to care for Medicaid
357 recipients, expand graduate medical education on an equitable
358 basis, and increase the supply of highly trained physicians
359 statewide. The agency shall make payments to hospitals licensed
360 under part I of chapter 395 for graduate medical education
361 associated with the Medicaid program. This system of payments is
362 designed to generate federal matching funds under Medicaid and
363 distribute the resulting funds to participating hospitals on a
364 quarterly basis in each fiscal year for which an appropriation
365 is made.
366 (2) On or before September 15 of each year, the agency
367 shall calculate an allocation fraction to be used for
368 distributing funds to participating hospitals. On or before the
369 final business day of each quarter of a state fiscal year, the
370 agency shall distribute to each participating hospital one
371 fourth of that hospital’s annual allocation calculated under
372 subsection (4). The allocation fraction for each participating
373 hospital is based on the hospital’s number of full-time
374 equivalent residents and the amount of its Medicaid payments. As
375 used in this section, the term:
376 (a) “Full-time equivalent,” or “FTE,” means a resident who
377 is in his or her initial residency period, which is defined as
378 the minimum number of years of training required before the
379 resident may become eligible for board certification by the
380 American Osteopathic Association Bureau of Osteopathic
381 Specialists or the American Board of Medical Specialties in the
382 specialty in which he or she first began training, not to exceed
383 5 years. A resident training beyond the initial residency period
384 is counted as 0.5 FTE, unless his or her chosen specialty is in
385 general surgery or primary care, in which case the resident is
386 counted as 1.0 FTE. For the purposes of this section, primary
387 care specialties include:
388 1. Family medicine;
389 2. General internal medicine;
390 3. General pediatrics;
391 4. Preventive medicine;
392 5. Geriatric medicine;
393 6. Osteopathic general practice;
394 7. Obstetrics and gynecology; and
395 8. Emergency medicine.
396 (b) “Medicaid payments” means the estimated total payments
397 for reimbursing a hospital for direct inpatient services for the
398 fiscal year in which the allocation fraction is calculated based
399 on the hospital inpatient appropriation and the parameters for
400 the inpatient diagnosis-related group base rate, including
401 applicable intergovernmental transfers, specified in the General
402 Appropriations Act, as determined by the agency.
403 (c) “Resident” means a medical intern, fellow, or resident
404 enrolled in a program accredited by the Accreditation Council
405 for Graduate Medical Education, the American Association of
406 Colleges of Osteopathic Medicine, or the American Osteopathic
407 Association at the beginning of the state fiscal year during
408 which the allocation fraction is calculated, as reported by the
409 hospital to the agency.
410 (3) The agency shall use the following formula to calculate
411 a participating hospital’s allocation fraction:
412
413 HAF=[0.9 x (HFTE/TFTE)] + [0.1 x (HMP/TMP)]
414
415 Where:
416 HAF=A hospital’s allocation fraction.
417 HFTE=A hospital’s total number of FTE residents.
418 TFTE=The total FTE residents for all participating
419 hospitals.
420 HMP=A hospital’s Medicaid payments.
421 TMP=The total Medicaid payments for all participating
422 hospitals.
423
424 (4) A hospital’s annual allocation shall be calculated by
425 multiplying the funds appropriated for the Statewide Medicaid
426 Residency Program in the General Appropriations Act by that
427 hospital’s allocation fraction. If the calculation results in an
428 annual allocation that exceeds $50,000 per FTE resident, the
429 hospital’s annual allocation shall be reduced to a sum equaling
430 no more than $50,000 per FTE resident. The funds calculated for
431 that hospital in excess of $50,000 per FTE resident shall be
432 redistributed to participating hospitals whose annual allocation
433 does not exceed $50,000 per FTE resident, using the same
434 methodology and payment schedule specified in this section.
435 (5) The agency may adopt rules to administer this section.
436 Section 6. Subsection (17) of section 409.910, Florida
437 Statutes, is amended to read:
438 409.910 Responsibility for payments on behalf of Medicaid
439 eligible persons when other parties are liable.—
440 (17) A recipient or his or her legal representative or any
441 person representing, or acting as agent for, a recipient or the
442 recipient’s legal representative, who has notice, excluding
443 notice charged solely by reason of the recording of the lien
444 pursuant to paragraph (6)(c), or who has actual knowledge of the
445 agency’s rights to third-party benefits under this section, who
446 receives any third-party benefit or proceeds therefrom for a
447 covered illness or injury, must is required either to pay the
448 agency, within 60 days after receipt of settlement proceeds, pay
449 the agency the full amount of the third-party benefits, but not
450 more than in excess of the total medical assistance provided by
451 Medicaid, or to place the full amount of the third-party
452 benefits in an interest-bearing a trust account for the benefit
453 of the agency pending an judicial or administrative
454 determination of the agency’s right to the benefits thereto.
455 Proof that any such person had notice or knowledge that the
456 recipient had received medical assistance from Medicaid, and
457 that third-party benefits or proceeds therefrom were in any way
458 related to a covered illness or injury for which Medicaid had
459 provided medical assistance, and that any such person knowingly
460 obtained possession or control of, or used, third-party benefits
461 or proceeds and failed either to pay the agency the full amount
462 required by this section or to hold the full amount of third
463 party benefits or proceeds in an interest-bearing trust account
464 pending an judicial or administrative determination, unless
465 adequately explained, gives rise to an inference that such
466 person knowingly failed to credit the state or its agent for
467 payments received from social security, insurance, or other
468 sources, pursuant to s. 414.39(4)(b), and acted with the intent
469 set forth in s. 812.014(1).
470 (a) A recipient may contest the amount designated as
471 recovered medical expense damages payable to the agency pursuant
472 to the formula specified in paragraph (11)(f) by filing a
473 petition under chapter 120 within 21 days after the date of
474 payment of funds to the agency or after the date of placing the
475 full amount of the third-party benefits in the trust account for
476 the benefit of the agency. The petition shall be filed with the
477 Division of Administrative Hearings. For purposes of chapter
478 120, the payment of funds to the agency or the placement of the
479 full amount of the third-party benefits in the trust account for
480 the benefit of the agency constitutes final agency action and
481 notice thereof. Final order authority for the proceedings
482 specified in this subsection rests with the Division of
483 Administrative Hearings. This procedure is the exclusive method
484 for challenging the amount of third-party benefits payable to
485 the agency.
486 1. In order to successfully challenge the amount payable to
487 the agency, the recipient must prove, by clear and convincing
488 evidence, that a lesser portion of the total recovery should be
489 allocated as reimbursement for past and future medical expenses
490 than the amount calculated by the agency pursuant to the formula
491 set forth in paragraph (11)(f) or that Medicaid provided a
492 lesser amount of medical assistance than that asserted by the
493 agency.
494 2. The agency’s provider processing system reports are
495 admissible as prima facie evidence in substantiating the
496 agency’s claim.
497 3. Venue for all administrative proceedings pursuant to
498 this subsection lies in Leon County, at the discretion of the
499 agency. Venue for all appellate proceedings arising from the
500 administrative proceeding outlined in this subsection lie at the
501 First District Court of Appeal in Leon County, at the discretion
502 of the agency.
503 4. Each party shall bear its own attorney fees and costs
504 for any administrative proceeding conducted pursuant to this
505 paragraph.
506 (b)(a) In cases of suspected criminal violations or
507 fraudulent activity, the agency may take any civil action
508 permitted at law or equity to recover the greatest possible
509 amount, including, without limitation, treble damages under ss.
510 772.11 and 812.035(7).
511 1.(b) The agency may is authorized to investigate and to
512 request appropriate officers or agencies of the state to
513 investigate suspected criminal violations or fraudulent activity
514 related to third-party benefits, including, without limitation,
515 ss. 414.39 and 812.014. Such requests may be directed, without
516 limitation, to the Medicaid Fraud Control Unit of the Office of
517 the Attorney General, or to any state attorney. Pursuant to s.
518 409.913, the Attorney General has primary responsibility to
519 investigate and control Medicaid fraud.
520 2.(c) In carrying out duties and responsibilities related
521 to Medicaid fraud control, the agency may subpoena witnesses or
522 materials within or outside the state and, through any duly
523 designated employee, administer oaths and affirmations and
524 collect evidence for possible use in either civil or criminal
525 judicial proceedings.
526 3.(d) All information obtained and documents prepared
527 pursuant to an investigation of a Medicaid recipient, the
528 recipient’s legal representative, or any other person relating
529 to an allegation of recipient fraud or theft is confidential and
530 exempt from s. 119.07(1):
531 a.1. Until such time as the agency takes final agency
532 action;
533 b.2. Until such time as the Department of Legal Affairs
534 refers the case for criminal prosecution;
535 c.3. Until such time as an indictment or criminal
536 information is filed by a state attorney in a criminal case; or
537 d.4. At all times if otherwise protected by law.
538 Section 7. Paragraph (a) of subsection (2) and paragraph
539 (d) of subsection (4) of section 409.911, Florida Statutes, are
540 amended to read:
541 409.911 Disproportionate share program.—Subject to specific
542 allocations established within the General Appropriations Act
543 and any limitations established pursuant to chapter 216, the
544 agency shall distribute, pursuant to this section, moneys to
545 hospitals providing a disproportionate share of Medicaid or
546 charity care services by making quarterly Medicaid payments as
547 required. Notwithstanding the provisions of s. 409.915, counties
548 are exempt from contributing toward the cost of this special
549 reimbursement for hospitals serving a disproportionate share of
550 low-income patients.
551 (2) The Agency for Health Care Administration shall use the
552 following actual audited data to determine the Medicaid days and
553 charity care to be used in calculating the disproportionate
554 share payment:
555 (a) The average of the 2004, 2005, and 2006, and 2007
556 audited disproportionate share data to determine each hospital’s
557 Medicaid days and charity care for the 2013-2014 2012-2013 state
558 fiscal year.
559 (4) The following formulas shall be used to pay
560 disproportionate share dollars to public hospitals:
561 (d) Any nonstate government owned or operated hospital
562 eligible for payments under this section on July 1, 2011,
563 remains eligible for payments during the 2013-2014 2012-2013
564 state fiscal year.
565 Section 8. Subsection (2) of section 409.9118, Florida
566 Statutes, is amended to read:
567 409.9118 Disproportionate share program for specialty
568 hospitals.— The Agency for Health Care Administration shall
569 design and implement a system of making disproportionate share
570 payments to those hospitals licensed in accordance with part I
571 of chapter 395 as a specialty hospital which meet all
572 requirements listed in subsection (2). Notwithstanding s.
573 409.915, counties are exempt from contributing toward the cost
574 of this special reimbursement for patients.
575 (2) In order to receive payments under this section, a
576 hospital must be licensed in accordance with part I of chapter
577 395, to participate in the Florida Title XIX program, and meet
578 the following requirements:
579 (a) Be certified or certifiable to be a provider of Title
580 XVIII services.
581 (b) Receive all of its inpatient clients through referrals
582 or admissions from county public health departments, as defined
583 in chapter 154.
584 (c) Require a diagnosis for the control of active
585 tuberculosis or a history of noncompliance with prescribed drug
586 regimens for the treatment of tuberculosis a communicable
587 disease for all admissions for inpatient treatment.
588 (d) Retain a contract with the Department of Health to
589 accept clients for admission and inpatient treatment pursuant to
590 s. 392.62.
591 Section 9. Paragraphs (b), (l), and (m) of subsection (2)
592 of section 409.9122, Florida Statutes, are amended, subsections
593 (3) through (21) of that section are renumbered as subsection
594 (4) through (22), respectively, and a new subsection (3) is
595 added to that section, to read:
596 409.9122 Mandatory Medicaid managed care enrollment;
597 programs and procedures.—
598 (2)
599 (b) A Medicaid recipient may shall not be enrolled in or
600 assigned to a managed care plan or MediPass unless the managed
601 care plan or MediPass has complied with the quality-of-care
602 standards specified in paragraphs (4)(a) (3)(a) and (b),
603 respectively.
604 (l) If the Medicaid recipient is diagnosed with HIV/AIDS,
605 the agency shall assign the Medicaid recipient to a managed care
606 plan that is a health maintenance organization authorized under
607 chapter 641, is under contract with the agency on July 1, 2011,
608 and which offers a delivery system through a university-based
609 teaching and research-oriented organization that specializes in
610 providing health care services and treatment for individuals
611 diagnosed with HIV/AIDS.
612 (l)(m) Notwithstanding the provisions of chapter 287, the
613 agency may, at its discretion, renew cost-effective contracts
614 for choice counseling services once or more for such periods as
615 the agency may decide. However, all such renewals may not
616 combine to exceed a total period longer than the term of the
617 original contract.
618
619 This subsection expires October 1, 2014.
620 (3) Notwithstanding s. 409.961, if a Medicaid recipient is
621 diagnosed with HIV/AIDS, the agency shall assign the recipient
622 to a managed care plan that is a health maintenance organization
623 authorized under chapter 641, that is under contract with the
624 agency as an HIV/AIDS specialty plan as of January 1, 2013, and
625 that offers a delivery system through a university-based
626 teaching and research-oriented organization that specializes in
627 providing health care services and treatment for individuals
628 diagnosed with HIV/AIDS. This subsection applies to recipients
629 who are subject to mandatory managed care enrollment and have
630 failed to choose a managed care option.
631 Section 10. Section 409.915, Florida Statutes, is amended
632 to read:
633 409.915 County contributions to Medicaid.—Although the
634 state is responsible for the full portion of the state share of
635 the matching funds required for the Medicaid program, in order
636 to acquire a certain portion of these funds, the state shall
637 charge the counties an annual contribution in order to acquire a
638 certain portion of these funds for certain items of care and
639 service as provided in this section.
640 (1) As used in this section, the term “state Medicaid
641 expenditures” means those expenditures used as matching funds
642 for the federal Medicaid program.
643 (2)(a) For the 2013-2014 state fiscal year, the total
644 amount of the counties’ annual contribution is $269.6 million.
645 (b) For the 2014-2015 state fiscal year, the total amount
646 of the counties’ annual contribution is $277 million.
647 (c) By March 15, 2015, and each year thereafter, the Social
648 Services Estimating Conference shall determine the percentage
649 change in state Medicaid expenditures by comparing expenditures
650 for the 2 most recent completed state fiscal years.
651 (d) For the 2015-2016 state fiscal year through the 2019
652 2020 state fiscal year, the total amount of the counties’ annual
653 contribution shall be the total contribution for the prior
654 fiscal year adjusted by 50 percent of the percentage change in
655 the state Medicaid expenditures as determined by the Social
656 Services Estimating Conference.
657 (e) For each fiscal year after the 2019-2020 state fiscal
658 year, the total amount of the counties’ annual contribution
659 shall be the total contribution for the prior fiscal year
660 adjusted by the percentage change in the state Medicaid
661 expenditures as determined by the Social Services Estimating
662 Conference.
663 (3)(a)1. The amount of each county’s annual contribution is
664 equal to the product of the amount determined under subsection
665 (2) multiplied by the sum of the percentages calculated in sub
666 subparagraphs a. and b.:
667 a. The enrollment weight provided in subparagraph 2. is
668 multiplied by a fraction, the numerator of which is the number
669 of the county’s Medicaid enrollees as of March 1 of each year,
670 and the denominator of which is the number of all counties’
671 Medicaid enrollees as of March 1 of each year. The agency shall
672 calculate this amount for each county and provide the
673 information to the Department of Revenue by May 15 of each year.
674 b. The payment weight provided in subparagraph 2. is
675 multiplied by the percentage share of payments provided in
676 subparagraph 3. for each county.
677 2. The weights for each fiscal year are equal to:
678
679 WEIGHTS
680
681
682 FISCAL YEAR ENROLLMENT PAYMENT
683
684
685
686
687
688
689
690
691 3. The percentage share of payments for each county is:
692
693
694
695 COUNTY SHARE OF PAYMENTS
696
697
698
699
700
701
702
703
704
705
706
707
708
709
710
711
712
713
714
715
716
717
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764 (b)1. The Legislature intends to replace the county
765 percentage share provided in subparagraph (a)3. with percentage
766 shares based upon each county’s proportion of the total
767 statewide amount of county billings made under this section from
768 April 1, 2012, through March 31, 2013, for which the state
769 ultimately receives payment.
770 2. By February 1 of each year and continuing until a
771 certification is made under sub-subparagraph b., the agency
772 shall report to the President of the Senate and the Speaker of
773 the House of Representatives the status of the county billings
774 made under this section from April 1, 2012, through March 31,
775 2013, by county, including:
776 a. The amounts billed to each county which remain unpaid,
777 if any; and
778 b. A certification from the agency of a final accounting of
779 the amount of funds received by the state from such billings, by
780 county, upon the expiration of all appeal rights that counties
781 may have to contest such billings.
782 3. By March 15 of the state fiscal year in which the state
783 receives the certification provided for in sub-subparagraph
784 (b)2.b., the Social Services Estimating Conference shall
785 calculate each county’s percentage share of the total statewide
786 amount of county billings made under this section from April 1,
787 2012, through March 31, 2013, for which the state ultimately
788 receives payment.
789 4. Beginning in the state fiscal year following the receipt
790 by the state of the certification provided in sub-subparagraph
791 (b)2.b., each county’s percentage share under subparagraph (a)3.
792 shall be replaced by the percentage calculated under
793 subparagraph (b)3.
794 5. If the court invalidates the replacement of each
795 county’s share as provided in this paragraph, the county share
796 set forth in subparagraph (a)3. shall continue to apply.
797 (4) By June 1 of each year, the Department of Revenue shall
798 notify each county of its required annual contribution. Each
799 county shall pay its contribution, by check or electronic
800 transfer, in equal monthly installments to the department by the
801 5th day of each month. If a county fails to remit the payment by
802 the 5th day of the month, the department shall reduce the
803 monthly distribution of that county pursuant to s. 218.61 and,
804 if necessary, by the amount of the monthly installment pursuant
805 to s. 218.26. The payments and the amounts by which the
806 distributions are reduced shall be transferred to the General
807 Revenue Fund.
808 (1) Each county shall participate in the following items of
809 care and service:
810 (a) For both health maintenance members and fee-for-service
811 beneficiaries, payments for inpatient hospitalization in excess
812 of 10 days, but not in excess of 45 days, with the exception of
813 pregnant women and children whose income is in excess of the
814 federal poverty level and who do not participate in the Medicaid
815 medically needy program, and for adult lung transplant services.
816 (b) For both health maintenance members and fee-for-service
817 beneficiaries, payments for nursing home or intermediate
818 facilities care in excess of $170 per month, with the exception
819 of skilled nursing care for children under age 21.
820 (2) A county’s participation must be 35 percent of the
821 total cost, or the applicable discounted cost paid by the state
822 for Medicaid recipients enrolled in health maintenance
823 organizations or prepaid health plans, of providing the items
824 listed in subsection (1), except that the payments for items
825 listed in paragraph (1)(b) may not exceed $55 per month per
826 person.
827 (3) Each county shall set aside sufficient funds to pay for
828 items of care and service provided to the county’s eligible
829 recipients for which county contributions are required,
830 regardless of where in the state the care or service is
831 rendered.
832 (4) Each county shall contribute its pro rata share of the
833 total county participation based upon statements rendered by the
834 agency. The agency shall render such statements monthly based on
835 each county’s eligible recipients. For purposes of this section,
836 each county’s eligible recipients shall be determined by the
837 recipient’s address information contained in the federally
838 approved Medicaid eligibility system within the Department of
839 Children and Family Services. A county may use the process
840 developed under subsection (10) to request a refund if it
841 determines that the statement rendered by the agency contains
842 errors.
843 (5) In any county in which a special taxing district or
844 authority is located which benefits will benefit from the
845 Medicaid program medical assistance programs covered by this
846 section, the board of county commissioners may divide the
847 county’s financial responsibility for this purpose
848 proportionately, and each such district or authority must
849 furnish its share to the board of county commissioners in time
850 for the board to comply with subsection (4) (3). Any appeal of
851 the proration made by the board of county commissioners must be
852 made to the Department of Financial Services, which shall then
853 set the proportionate share for of each party.
854 (6) Counties are exempt from contributing toward the cost
855 of new exemptions on inpatient ceilings for statutory teaching
856 hospitals, specialty hospitals, and community hospital education
857 program hospitals that came into effect July 1, 2000, and for
858 special Medicaid payments that came into effect on or after July
859 1, 2000.
860 (6)(7)(a) By August 1, 2012, the agency shall certify to
861 each county the amount of such county’s billings from November
862 1, 2001, through April 30, 2012, which remain unpaid. A county
863 may contest the amount certified by filing a petition under the
864 applicable provisions of chapter 120 on or before September 1,
865 2012. This procedure is the exclusive method to challenge the
866 amount certified. In order to successfully challenge the amount
867 certified, a county must show, by a preponderance of the
868 evidence, that a recipient was not an eligible recipient of that
869 county or that the amount certified was otherwise in error.
870 (b) By September 15, 2012, the agency shall certify to the
871 Department of Revenue:
872 1. For each county that files a petition on or before
873 September 1, 2012, the amount certified under paragraph (a); and
874 2. For each county that does not file a petition on or
875 before September 1, 2012, an amount equal to 85 percent of the
876 amount certified under paragraph (a).
877 (c) The filing of a petition under paragraph (a) does shall
878 not stay or stop the Department of Revenue from reducing
879 distributions in accordance with paragraph (b) and subsection
880 (7) (8). If a county that files a petition under paragraph (a)
881 is able to demonstrate that the amount certified should be
882 reduced, the agency shall notify the Department of Revenue of
883 the amount of the reduction. The Department of Revenue shall
884 adjust all future monthly distribution reductions under
885 subsection (7) (8) in a manner that results in the remaining
886 total distribution reduction being applied in equal monthly
887 amounts.
888 (7)(8)(a) Beginning with the October 2012 distribution, the
889 Department of Revenue shall reduce each county’s distributions
890 pursuant to s. 218.26 by one thirty-sixth of the amount
891 certified by the agency under subsection (6) (7) for that
892 county, minus any amount required under paragraph (b). Beginning
893 with the October 2013 distribution, the Department of Revenue
894 shall reduce each county’s distributions pursuant to s. 218.26
895 by one forty-eighth of two-thirds of the amount certified by the
896 agency under subsection (6) (7) for that county, minus any
897 amount required under paragraph (b). However, the amount of the
898 reduction may not exceed 50 percent of each county’s
899 distribution. If, after 60 months, the reductions for any county
900 do not equal the total amount initially certified by the agency,
901 the Department of Revenue shall continue to reduce such county’s
902 distribution by up to 50 percent until the total amount
903 certified is reached. The amounts by which the distributions are
904 reduced shall be transferred to the General Revenue Fund.
905 (b) As an assurance to holders of bonds issued before the
906 effective date of this act to which distributions made pursuant
907 to s. 218.26 are pledged, or bonds issued to refund such bonds
908 which mature no later than the bonds they refunded and which
909 result in a reduction of debt service payable in each fiscal
910 year, the amount available for distribution to a county shall
911 remain as provided by law and continue to be subject to any lien
912 or claim on behalf of the bondholders. The Department of Revenue
913 must ensure, based on information provided by an affected
914 county, that any reduction in amounts distributed pursuant to
915 paragraph (a) does not reduce the amount of distribution to a
916 county below the amount necessary for the timely payment of
917 principal and interest when due on the bonds and the amount
918 necessary to comply with any covenant under the bond resolution
919 or other documents relating to the issuance of the bonds. If a
920 reduction to a county’s monthly distribution must be decreased
921 in order to comply with this paragraph, the Department of
922 Revenue must notify the agency of the amount of the decrease and
923 the agency must send a bill for payment of such amount to the
924 affected county.
925 (9)(a) Beginning May 1, 2012, and each month thereafter,
926 the agency shall certify to the Department of Revenue by the 7th
927 day of each month the amount of the monthly statement rendered
928 to each county pursuant to subsection (4). Beginning with the
929 May 2012 distribution, the Department of Revenue shall reduce
930 each county’s monthly distribution pursuant to s. 218.61 by the
931 amount certified by the agency minus any amount required under
932 paragraph (b). The amounts by which the distributions are
933 reduced shall be transferred to the General Revenue Fund.
934 (b) As an assurance to holders of bonds issued before the
935 effective date of this act to which distributions made pursuant
936 to s. 218.61 are pledged, or bonds issued to refund such bonds
937 which mature no later than the bonds they refunded and which
938 result in a reduction of debt service payable in each fiscal
939 year, the amount available for distribution to a county shall
940 remain as provided by law and continue to be subject to any lien
941 or claim on behalf of the bondholders. The Department of Revenue
942 must ensure, based on information provided by an affected
943 county, that any reduction in amounts distributed pursuant to
944 paragraph (a) does not reduce the amount of distribution to a
945 county below the amount necessary for the timely payment of
946 principal and interest when due on the bonds and the amount
947 necessary to comply with any covenant under the bond resolution
948 or other documents relating to the issuance of the bonds. If a
949 reduction to a county’s monthly distribution must be decreased
950 in order to comply with this paragraph, the Department of
951 Revenue must notify the agency of the amount of the decrease and
952 the agency must send a bill for payment of such amount to the
953 affected county.
954 (10) The agency, in consultation with the Department of
955 Revenue and the Florida Association of Counties, shall develop a
956 process for refund requests which:
957 (a) Allows counties to submit to the agency written
958 requests for refunds of any amounts by which the distributions
959 were reduced as provided in subsection (9) and which set forth
960 the reasons for the refund requests.
961 (b) Requires the agency to make a determination as to
962 whether a refund request is appropriate and should be approved,
963 in which case the agency shall certify the amount of the refund
964 to the department.
965 (c) Requires the department to issue the refund for the
966 certified amount to the county from the General Revenue Fund.
967 The Department of Revenue may issue the refund in the form of a
968 credit against reductions to be applied to subsequent monthly
969 distributions.
970 (8)(11) Beginning in the 2013-2014 fiscal year and each
971 year thereafter through the 2020-2021 fiscal year, the Chief
972 Financial Officer shall transfer from the General Revenue Fund
973 to the Lawton Chiles Endowment Fund an amount equal to the
974 amounts transferred to the General Revenue Fund in the previous
975 fiscal year pursuant to subsections (4) and (7) subsections (8)
976 and (9), reduced by the amount of refunds paid pursuant to
977 subsection (10), which are in excess of the official estimate
978 for medical hospital fees for such previous fiscal year adopted
979 by the Revenue Estimating Conference on January 12, 2012, as
980 reflected in the conference’s workpapers. By July 20 of each
981 year, the Office of Economic and Demographic Research shall
982 certify the amount to be transferred to the Chief Financial
983 Officer. Such transfers must be made before July 31 of each year
984 until the total transfers for all years equal $350 million. If
985 In the event that such transfers do not total $350 million by
986 July 1, 2021, the Legislature shall provide for the transfer of
987 amounts necessary to total $350 million. The Office of Economic
988 and Demographic Research shall publish the official estimates
989 reflected in the conference’s workpapers on its website.
990 (9)(12) The agency may adopt rules to administer this
991 section.
992 Section 11. Notwithstanding s. 409.915(3) and (4), Florida
993 Statutes, as amended by this act, the amount of each county’s
994 contribution during the 2013-2014 state fiscal year shall be
995 determined and provided to the Department of Revenue by the
996 Agency for Health Care Administration by June 15, 2013. The
997 Department of Revenue shall notify each county of its annual
998 contribution by June 20, 2013.
999 Section 12. The Agency for Health Care Administration shall
1000 submit a data report by March 1 of each year to the Governor,
1001 the President of the Senate, the Speaker of the House of
1002 Representatives, and the Florida Association of Counties which
1003 includes such information as may be necessary for
1004 comprehensively evaluating the cost and utilization of health
1005 services by Medicaid enrollees by service type in each county.
1006 This section is repealed December 31, 2015.
1007 Section 13. The paragraph following Specific Appropriation
1008 195 contained in SB 1500, if adopted during the 2013 Regular
1009 Session of the Florida Legislature, is repealed and replaced
1010 with the following upon SB 1500 becoming a law:
1011
1012 From the funds in Specific Appropriations 195, 197,
1013 198, 201, 203, 215, 219, 222, and 223, $677,722,971
1014 from the Medical Care Trust Fund is provided for
1015 increased reimbursement rates for primary care
1016 services provided to eligible Medicaid recipients.
1017
1018 Section 14. This act shall take effect July 1, 2013.
1019
1020 ================= T I T L E A M E N D M E N T ================
1021 And the title is amended as follows:
1022 Delete everything before the enacting clause
1023 and insert:
1024 A bill to be entitled
1025 An act relating to Medicaid; repealing s. 381.0403,
1026 F.S., relating to the Community Hospital Education
1027 Act; amending s. 395.602, F.S.; providing that certain
1028 rural hospitals remain rural hospitals under specified
1029 circumstances; amending s. 409.905, F.S.; requiring
1030 the Agency for Health Care Administration to implement
1031 a prospective payment system for inpatient hospital
1032 services using diagnosis-related groups (DRGs);
1033 deleting provisions directing the agency to develop a
1034 plan to convert hospital reimbursement for inpatient
1035 services to a prospective payment system; requiring
1036 hospital reimbursement for outpatient services to be
1037 based on allowable costs; providing that adjustments
1038 may not be made after a certain date; providing for
1039 the reconciliation of errors in source data or
1040 calculations; amending s. 409.908, F.S.; revising
1041 exceptions to limitations on hospital reimbursement
1042 for inpatient services; providing parameters for
1043 submission of letters of agreement by local
1044 governmental entities to the agency relating to funds
1045 for special payments; providing that base rate
1046 reimbursement under a diagnosis-related group
1047 methodology shall be established in the General
1048 Appropriations Act; creating s. 409.909, F.S.;
1049 establishing the Statewide Medicaid Residency Program;
1050 providing the purposes of the program; providing
1051 definitions; providing a formula and limitations for
1052 allocating funds to participating hospitals;
1053 authorizing the agency to adopt rules; amending s.
1054 409.910, F.S.; revising provisions relating to
1055 responsibility for Medicaid payments in settlement
1056 proceedings; providing procedures for a recipient to
1057 contest the amount payable to the agency; amending s.
1058 409.911, F.S.; updating references to data used for
1059 calculations in the disproportionate share program;
1060 amending s. 409.9118, F.S.; amending parameters for
1061 the disproportionate share program for specialty
1062 hospitals; limiting reimbursement to tuberculosis
1063 services provided under contract with the Department
1064 of Health; amending s. 409.9122, F.S.; providing that
1065 certain mandatory managed care provisions that apply
1066 to a Medicaid recipient diagnosed with HIV/AIDS apply
1067 only to a recipient who failed to choose a managed
1068 care option; amending s. 409.915, F.S.; specifying the
1069 total contribution for certain years and specifying
1070 the method for determining the amount in the following
1071 years; revising the method for calculating each
1072 county’s contribution; providing tables for
1073 calculating county contributions; requiring the Agency
1074 for Health Care Administration to annually report the
1075 status of county billings to the Legislature;
1076 authorizing the Department of Revenue to withhold
1077 county distributions for failure to remit Medicaid
1078 contributions; deleting provisions specifying the care
1079 and services that counties must participate in,
1080 obsolete bond provisions, and a process for refund
1081 requests; specifying the method for calculating each
1082 county’s contribution for the 2013-2014 fiscal year;
1083 requiring the agency to submit an annual report to the
1084 Governor, the Legislature, and the Florida Association
1085 of Counties which includes information necessary to
1086 comprehensively evaluate the cost and utilization of
1087 health services by Medicaid enrollees; providing for
1088 the repeal and replacement of specified proviso in the
1089 2031-2014 General Appropriations Act; providing an
1090 effective date.